North East London (NEL) Management of Infection Guidance

for Primary Care

Adapted from the Public Health England (PHE) Management of infection guidance for
primary care for consultation and local adaptation – last updated May 2017

The guidelines have been developed in collaboration with:

- Barking, Havering and Redbridge University NHS Trust (BHRuT) Microbiology teams
- Barts Health NHS Trust Microbiology teams
- Homerton University Hospital NHS Foundation Trust Microbiology team (HUHFT)
- Barking and Dagenham, Havering and Redbridge (BHR) Clinical Commissioning
Groups (CCGs)
- City and Hackney (C&H) CCG
- East London Foundation Trust
- Newham CCG
- North East London Foundation NHS Trust (NELFT)
- Tower Hamlets CCG
- Waltham Forest CCG

The guideline review group has involved a range of healthcare professionals including GPs,
Microbiologists/Infectious disease consultants, Primary Care Pharmacists/Prescribing
Advisors, and Antimicrobial Pharmacists. Advice has also be sought from local dermatologists,
obstetricians and gastroenterologists where appropriate.

For a full list of evidence and references for each infection please refer to the main Public
health England document available here. They strength of each recommendation is qualified
by a letter in parenthesis. This is an altered version of the grading recommendation system
used by SIGN.

Date approved: August 2017

Date of review: July 2019, or sooner if required
Version: 5.13 Updated April 2019
 Version Control

Version Name Date Comments

4.0 Creation of the NEL document July 2017 Update to incorporate PHE recommendations in
pregnancy led by Hassan Sergini (WF CCG)
5.0, 5.1, 5.2 Document August 2017 Formatting

5.3 Urinary Tract Infections August 2017 Updated with comments from Dr Alleyna Claxton
(Homerton) and Dr Mark Melzer (Barts Health)
and Dr Sandra Lacey (BHRuT)
5.4 Contact August 2017 Update with BHRuT GP Microbiologist contact
details
5.5 Document August 2017 Inclusion of guideline review group on page 3
5.6 Document August 2017 Formatting

5.7 Urinary Tract Infections September 2017 - Included link on page 27

- Add Ann Chan, Senior Prescribing Advisor,
(Tower Hamlets) to guideline review group
5.8 Urinary Tract Infections January 2018 TARGET UTI hyperlink updated and the Target
UTI leaflet link on section 2
5.9 Upper Respiratory Tract May 2018 Formatting of the table and insertion of hyperlink
Infections (Otitis Media and to the NICE visual summary
Sinusitis)
5.10 Upper Respiratory Tract June 2018 -Entire NICE Visual Summary embedded into the
Infections guidance
- Version Control page included.
Gastrointestinal Tract Infection -Removed a typo (3C) under section Infectious
2ecoloni
- Include blank page 5
-Logos removed from all pages after page 1
5.11 NICE NG95 – Lyme Disease August 2018 Entire NICE Visual Summary and antibiotic
treatment recommendation embedded into the
guidance at the end of the Skin infections (pages
31-34)

5.12 Gential Tract Infections – November 2018 -Recommended first line treatment option in line
Chlamydia (uncomplicated with the updated BASHH Guidelines (September
urogenital, pharyngeal and 2018)
rectal infection) /Urethritis

North East and North Central - Pages, 25,29 and 31 updated with current
London Health Protection contact details for the team
Team Contact

Skin Infections – -Insertion of MRSA 2ecolonization Protocol

MRSA Colonisation produced by Antimicrobial Pharmacists from Barts
Health, Homerton Hospital and BHRUT

Section 2: Information for -Insertion of the link to the PHE PVL

Patients Staphylococcus aureus patient information leaflet,
page 37

References - British Association for Sexual Health and HIV link

updated for Chlamydia 2015 (Updated Sept
2018) page 39

2|Page
 Blank Page 5 March 2019 - Moved to page 6
5.13
Lower Respiratory Tract - Updated with the current NICE guidelines (Dec
Infections – Acute 2018) Page 16
exacerbation of COPD

Urinary Tract Infections - Updated with the current NICE Guidelines (Oct
- UTI (Catheter) 2018) Page 26
- UTI in Adults (lower) - Updated with the current NICE Guidelines (Oct
- Acute Prostatitis 2018) Page 21
- Acute Pyelonephritis - Updated with the current NICE Guidelines (Oct
- UTI (recurrent) 2018) page 24
- Updated with the current NICE Guidelines (Oct
2018) page 29
- Updated with the current NICE Guidelines (Oct
2018) page 32
Genital Tract Infections
- Chlamydia (uncomplicated - Addition of text under Azithromycin; If allergic or
urogenital pharyngeal and intolerant to tetracyclines and pregnant women)
rectal infections)/ uretritis

3|Page
For further information please contact a member of the CCG based medicines
management/optimisation teams on

Phone
CCG Email contact
number

BHR CCGs [email protected] 0203 182 3133

City and Hackney CCG [email protected] 0203 816 3224

Newham [email protected] 0203 688 2353

Tower Hamlets [email protected] 020 3688 2556

Waltham Forest [email protected] 020 3688 2652

Microbiology team contact Contact details

Barking, Havering and Redbridge GP Microbiologist via switchboard at Queens

University NHS trust Telephone: 01708 435000

Barts Health NHS Trust Tower Hamlets GP phone 07710920866, WX GP enquiries

WXH, bleep 422 and NUH GP enquiries 07887856174

Homerton University Hospital NHS Microbiology: air-call through switchboard

Foundation Trust Antimicrobial pharmacist: bleep 209.
HUH switch: 0208 510 5555

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Guideline review group
Name Title
Senior Prescribing Advisor, Medicines Optimisation Team,
Hassan Sergini
Waltham Forest CCG

Oge Chesa Deputy Chief Pharmacist, BHR CCGs

Consultant Public Health Microbiologist for South East London Public

Dr Albert J Mifsud
Health England London Public Health Laboratory

Dr Mark Melzer Consultant in Microbiology / Infectious Diseases, Barts Health

Microbiology Consultant, ICD & DIPC, Strategic Antimicrobial

Dr Alleyna Claxton
Stewardship Lead, HUHFT

Dr Sandra Lacey Consultant Microbiologist, BHRuT

Sagal Hashi Joint Formulary Pharmacist, Medicines Management, C&H CCG

Manisha Madhani Antimicrobial Pharmacist, BHRuT

Maninder Kaur Singh Lead Prescribing Advisor, NHS Newham CCG

Anh Vu Project & Practice Pharmacist, C&H CCG

Heather Walker Chief Pharmacist, NELFT

Senior Prescribing Advisor, Tower Hamlets Medicines Management

Ann Chan
Team

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6|Page
 Contents

Table of Contents
Version Control ..................................................................................................................................... 2
Guideline review group ........................................................................................................................ 5
Policy Statement ................................................................................................................................... 8
Aims and Objectives of the Guidance ................................................................................................... 8
Principles of treatment ......................................................................................................................... 9
Section 1: Antibiotic formulary .......................................................................................................... 10
EYE INFECTIONS .................................................................................................................................. 10
DENTAL INFECTIONS ........................................................................................................................... 10
UPPER RESPIRATORY TRACT INFECTIONS ........................................................................................... 12
UPPER RESPIRATORY TRACT INFECTIONS CONTINUED ....................................................................... 12
LOWER RESPIRATORY TRACT INFECTIONS .......................................................................................... 16
GASTROINTESTINAL TRACT INFECTIONS ............................................................................................. 19
URINARY TRACT INFECTIONS .............................................................................................................. 21
GENITAL TRACT INFECTIONS ............................................................................................................... 34
MENINGITIS ........................................................................................................................................ 36
SKIN INFECTIONS ................................................................................................................................ 37
MRSA Decolonisation Protocol ........................................................................................................... 39
LYME DISEASE: laboratory investigations and diagnosis .................................................................... 43
Section 2: Information for patients .................................................................................................... 48
Section 3: Notification of Infectious Diseases .................................................................................... 49
References .......................................................................................................................................... 50
Useful Links......................................................................................................................................... 50

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Policy Statement

These guidelines are to be read in conjunction with current NICE and PHE guidance, BASHH,
CKS and RCGP Target Toolkit. Evidence-based antimicrobial prescribing is essential to begin
to address the challenge of increasingly antibiotic-resistant bacteria, and the rise in health care
acquired infections. The Health and Social Care Act 2008 (updated 2011) introduces the Code
of Practice for the Prevention and Control of HealthCare Associated Infections, also known as
the Hygiene Code. This Code requires all health care organisations to have a policy in place on
antimicrobial prescribing, in order to reduce the incidence and prevalence of Health Care
Associated Infections (HCAI). Where possible, treatment is based on national guidance
(Public Health England: Management of infection guidance for primary care for consultation
and local adaptation). Local adaptation has been applied where required on advice of the local
acute trusts department of infection, based on local sensitivities and resistance patterns.
Infections account for a large proportion of the acute workload seen in general practice and
cause considerable patient distress. The prescriber is sometimes put under pressure to
prescribe by patients who perceive that antibiotics will provide quick resolution, particularly if
they are under pressure to return to work.
However, the evidence to support antibiotic treatment is often weak or lacking, and certain
illnesses can be self-limiting. Good communication between the prescriber and patient, with
adequate time given to the consultation, is known to bring about more selective and
appropriate prescribing

Aims and Objectives of the Guidance

The guidance is presented in three parts: -
 Section 1: The antibiotic formulary and recommendations for the North East London
region
 Section 2: Information for patients.
 Section 3: Clinical cases where statutory notification of infectious diseases is required.

The aims are to:

 Support the rational, safe and cost-effective use of antibiotics by selecting the best
approach to managing common infections from the evidence available.

 Promote the selective use of antibiotics to reduce the emergence of antimicrobial

resistance in the community.

 Empower patients with information and support mechanisms so they can cope with
their infection.

The objectives are to:

 Assist prescribers in managing individuals with infections by providing clear information

on the likely clinical outcome with or without treatment and to indicate possible risk.
 Help the prescriber decide whether or not antibiotic treatment is indicated and which
antibiotic is the most appropriate.

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Principles of treatment

 Prescribe antibiotics only when there is likely to be a clear clinical benefit

 Use narrow spectrum antibiotics first
 Save broader spectrum antibiotics for non-responding or resistant infections.
 Serious allergic reactions to penicillin antibiotics are very uncommon. Anaphylactic occurs in one in
7,000 to one in 25,000 treated patients. Patients should be asked if they have experienced an
immediate reaction to administration of penicillin (or other antibiotic they report allergy to) such as
difficulty in breathing, collapse, rapid onset of a generalised urticarial (wheals/’hives’) itchy rash; in
these circumstances, the antibiotic should not be prescribed. If a history of delayed rash (after more
than a day of administration) is given, then the antibiotic should be avoided. However, most people
who give a history of penicillin allergy do not have a true allergy, describing symptoms such as
nausea and heartburn, which do not indicate allergy.
 In pregnancy, take specimens to inform treatment, use this guidance or seek expert advice.
Penicillins, cephalosporins and erythromycin are not associated with increased risks. If possible,
avoid tetracyclines, quinolones, aminoglycosides, azithromycin, clarithromycin, high dose
metronidazole (2g stat) unless the benefits outweigh the risks. Short-term use of nitrofurantoin is
not expected to cause foetal problems (theoretical risk of neonatal haemolysis). Trimethoprim is
also unlikely to cause problems unless poor dietary folate intake, or taking another folate antagonist
(Updated advice May 2017)
 Offer a deferred prescription in cases where the need for antibiotic therapy is equivocal, and safety
net with clear instructions to the patient as to when they should take it.
 Always refer to up to date up to date BNF, SPC and MHRA for up to date drug information
 Do not prescribe an antibiotic for a simple cold or for all sore throat
 Avoid repeated use of topical antibiotics, as they select for resistant organisms.
 Avoid the use of broad spectrum antibiotics such as co-amoxiclav, quinolones and cephalosporins
unless specifically indicated.

This guidance should always be applied in conjunction with clinical

judgement and consideration of important individual case factors including
allergy, pregnancy, drug interactions.
The recommendations apply only in the absence of contra- indications.
Please refer to the latest BNF or SmPC for further information.

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 Section 1: Antibiotic formulary

ILLNESS COMMENTS DRUG ADULT DOSE Duration of

Treatment
EYE INFECTIONS
Treat only if severe, as most is viral
Conjunctivitis
or self-limiting. If severe:
2 hourly for
chloramphenicol 0.5% 2 days, then
Bacterial conjunctivitis is usually
drop and 1% ointment 4 hourly (whilst All for 48
unilateral and also self-limiting; it is
awake) ointment hours after
characterised by red eye with
to be used at resolution
mucopurulent, not watery, discharge;
night
Second line:
Fusidic acid 1% gel Twice a day

DENTAL INFECTIONS

The prescribing of antibiotics for dental infections by primary health care practitioners is not recommended.
Patients should be advised in all instances to see their local dentist and sign posted to NHS choices or 111. The
information below has been provided as guidance and only where it is deemed clinically necessary should antibiotic
therapy be prescribed by the GP. This would also apply to dental mouthwashes that can either purchased or
obtained from a dentist. Exclusions will apply such as cancer patients.

In cases of significant swelling, GP need to urgently refer to a local hospital with a maxillofacial team to make
sure that airway is protected and start both surgical and antimicrobial treatment.

Temporary pain and swelling relief ½ tsp salt

Simple saline dissolved in
can be attained with saline
mouthwash mouthwash glass warm Always spit
water out after use
Use antiseptic mouthwash:
Rinse mouth for
If more severe and pain limits oral Chlorhexidine 0.12- 1 minute BD
hygiene to treat or prevent secondary 0.2% (Do not use
with 5 ml diluted
infection within 30 mins of
Mucosal with 5-10 ml
toothpaste)
ulceration and water only if
inflammation The primary cause for mucosal patient does not
(simple gingivitis) ulceration or inflammation tolerate
(aphthous ulcers, oral lichen mouthwash.
planus, herpes simplex infection,
oral cancer) needs to be evaluated
and treated. N.B the presence of Hydrogen peroxide Rinse mouth for Use until
white/red patches, chronic or 6%- (spit out after use) 2 mins TDS with lesions
recurrent oral ulcers should 15ml diluted in resolve or less
prompt referral to oral medicine or ½ glass warm pain allows
oral surgery specialist for water oral hygiene
diagnosis and treatment.
200-400 mg
3 days
Metronidazole TDS
Commence metronidazole and refer
Acute necrotising to dentist for scaling and oral hygiene
ulcerative advice
gingivitis Use in combination with antiseptic See above
mouthwash if pain limits oral hygiene Until oral
Chlorhexidine or dosing in
hygiene
hydrogen peroxide mucosal
possible
ulceration

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 Duration of
COMMENTS DRUG ADULT DOSE
ILLNESS Treatment
DENTAL INFECTIONS CONTINUED

Refer to dentist for irrigation &

Amoxicillin +/- 500mg TDS 3 days
debridement.
If persistent swelling or systemic
symptoms prescribe antimicrobial
according to the severity of the case Metronidazole 400mg TDS 3 days
and patient allergy history (see drug
choices column)
see above
Pericoronitis Chlorhexidine or dosing in Until oral
hydrogen peroxide mucosal hygiene
Use antiseptic mouthwash if pain and ulceration possible
trismus limit oral hygiene

If penicillin allergy
Clarithromycin 500mg BD 3 days
Or if severe
Clindamycin 300mg QDS 3 days
Regular analgesia should be first option until a dentist can be seen for urgent drainage, as repeated
courses of 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 complications.

Severe odontogenic infections; defined as cellulitis plus signs of sepsis, difficulty in swallowing,
impending airway obstruction, Ludwig’s angina requires urgent referral for surgical
intervention/management. Refer urgently for admission to protect airway, achieve surgical drainage
and IV antibiotics

The empirical use of cephalosporins, co-amoxiclav, clarithromycin, and clindamycin do not offer any
advantage for most dental patients and should only be used if no response to first line drugs when
referral is the preferred option.

If pus drain by incision, tooth Up to 5 days

extraction or via root canal. Send pus Amoxicillin 500mg TDS review at
for microbiology. 3days

Severe infection: add

Dental abscess If spreading infection (lymph node
Metronidazole 400mg TDS 5 days
involvement, or systemic signs i.e.
fever or malaise) ADD metronidazole
or
True penicillin allergy: use
clarithromycin or clindamycin if prescribe Clindamycin 300mg QDS 5 days
severe.

True penicillin
allergy: Clarithromycin
If severe add Up to 5 days
Metronidazole 500mg BD review at 3d
5 days
Or prescribe 400 mg TDS
Clindamycin 5days
300mg QDS

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 Duration of
ILLNESS COMMENTS DRUG ADULT DOSE
Treatment
DENTAL INFECTIONS CONTINUED

Topical azoles more effective than Miconazole oral gel

Oral candidiasis
topical nystatin. Oral candidiasis rare 20mg/mL QDS 7 days or
in immunocompetent adults; consider If miconazole not until 2 days
undiagnosed risk factors including tolerated nystatin 100,000 after
HIV. suspension units/mL QDS symptoms
Fluconazole if extensive/severe
candidiasis; if HIV or Fluconazole oral 50mg OD OR 7 days;
immunosuppression use 100mg. tablets 100mg OD further 7 days
if persistent

ILLNESS COMMENTS DRUG ADULT DOSE Duration of

Treatment

UPPER RESPIRATORY TRACT INFECTIONS

Annual vaccination is essential for all those at risk of influenza. For otherwise healthy adults
antivirals not recommended.
Treat ‘at risk’ patients, when influenza is circulating in the community and ideally within 48 hours
Influenza treatment of onset (do not wait for lab report) or in a care home where influenza is likely.
PHE Influenza At risk: pregnant (including up to two weeks post-partum), 65 years or over, chronic respiratory
For prophylaxis disease (including COPD and asthma), significant cardiovascular disease (not hypertension),
see: NICE Influenza immunocompromised, diabetes mellitus, chronic neurological, renal or liver disease, morbid obesity
(BMI>=40). Use 5 days treatment with oseltamivir 75mg bd. If resistance to oseltamivir or severe
immunosuppression, use zanamivir 10mg BD (2 inhalations by diskhaler for up to 10 days) and seek
advice. See PHE Influenza guidance for treatment of patients under 13 years or in severe
immunosuppression (and seek advice).
Avoid antibiotics as 90% resolve
in 7 days without, and pain only
reduced by 16 hours.
Phenoxymethylpenicillin
500mg QDS 10 days
Use FeverPAIN Score: or 1G BD
Fever in last 24h,
Purulence, (500mg QDS
Attend rapidly under 3d, severely when severe)
Inflamed tonsils,
No cough or coryza).
Score 0-1: 13-18% streptococci,
Penicillin Allergy:
use NO antibiotic strategy;
Clarithromycin
Acute sore throat 2-3: 34-40% streptococci, use 3 250-500mg BD 5 days
day back-up antibiotic;
4 or more: 62-65% streptococci
use immediate antibiotic if severe,
or 48hr short back-up prescription.

Always share self-care advice &

safety net.
Antibiotics to prevent quinsy NNT Pregnant &
>4000. Penicillin Allergy:
Antibiotics to prevent otitis media 5 days
Erythromycin
NNT 200. 500mg QDS
10d penicillin lower relapse vs 7d in
<18yrs.

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 UPPER RESPIRATORY TRACT INFECTIONS CONTINUED

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 UPPER RESPIRATORY TRACT INFECTIONS CONTINUED

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 UPPER RESPIRATORY TRACT INFECTIONS CONTINUED

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 Duration of
ILLNESS COMMENTS DRUG ADULT DOSE Treatment

LOWER RESPIRATORY TRACT INFECTIONS

Note: Low doses of penicillin’s are more likely to select out resistance, we recommend 500mg of amoxicillin. Do not use
quinolone (ciprofloxacin, ofloxacin) first line due to poor pneumococcal activity. Reserve all quinolones (including
levofloxacin) for proven resistant organisms.
In primary care, antibiotics have
marginal benefits in otherwise
healthy adults.
Patient leaflets can reduce antibiotic
use.

Antibiotic little benefit if no co-

morbidity.
Consider 7day delayed antibiotic
with advice.
Acute Symptom resolution can take 3 If comorbidity:
cough, weeks.
bronchitis Consider immediate antibiotics if > Amoxicillin or 500mg TDS
80yr and ONE of: hospitalisation in
past year, oral steroids, diabetic, 5 days
Doxycycline
congestive heart failure OR > 65yrs
with 2 of above. 200mg stat then
Consider CRP test if antibiotic being 100mg OD
considered.
If CRP<20mg/L no antibiotics, 20-
100mg/L delayed, CRP >100mg
immediate antibiotics.

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1 See BNF for appropriate use and dosing in specific populations, for example, hepatic impairment, renal impairment, and for administering intravenous antibiotics.
2 Where a person is receiving antibiotic prophylaxis, treatment should be with an antibiotic from a different class.
3 People who may be at higher risk of treatment failure include people who have had repeated courses of antibiotics, a previous or current sputum culture with resistant bacteria, or people at higher
risk of developing complications.
4 The European Medicines Agency’s Pharmacovigilance Risk Assessment Committee has recommended restricting the use of fluoroquinolone antibiotics following a review of disabling and potentially
long-lasting side effects mainly involving muscles, tendons, bones and the nervous system. This includes a recommendation not to use them for mild or moderately severe infections unless other
antibiotics cannot be used (press release October 2018).
5 Co-trimoxazole should only be considered for use in acute exacerbations of COPD when there is bacteriological evidence of sensitivity and good reason to prefer this combination to a single
antibiotic (BNF, October 2018).

When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the
people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the
individual, in consultation with them and their families and carers or guardian.

17 | P a g e
 Duration of
ILLNESS COMMENTS DRUG ADULT DOSE
Treatment

LOWER RESPIRATORY TRACT INFECTIONS continued

Community Use CRB65 score to help guide and IF CRB65=0:

acquired review: Each scores 1: Amoxicillin 500mg TDS CRB65=0: use
pneumonia - or Clarithromycin 500mg BD 5 days.
treatment in the Confusion (AMT<8); or Doxycycline 200mg Review
community Respiratory rate >30/min; stat/100mg OD at 3 days &
BP systolic <90 or diastolic ≤ 60 extend to 7-10
Age >65. days if poor
Response.
Score 0: suitable for home treatment; If CRB65=1,2 and AT
Score 1-2: hospital assessment or HOME
admission. Amoxicillin AND 500mg TDS 7-10 days
Score 3-4: urgent hospital admission Clarithromycin 500mg BD
Mycoplasma infection is rare in over
65s. or Doxycycline alone 200mg
stat/100mg OD
Always give safety-net advice and
likely duration of symptoms as per
NICE QS110.
Note: Do not prescribe tetracyclines in pregnancy. Ciprofloxacin and ofloxacin have poor activity against
pneumococci and should not normally be used

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 Duration of
ILLNESS COMMENTS DRUG ADULT DOSE
Treatment
GASTROINTESTINAL TRACT INFECTIONS

Treat all positives if known DU, GU Always use PPI. TWICE DAILY
low grade MALToma, or NNT in Non- (NO need to continue
Ulcer dyspepsia. PPI beyond
Do not offer eradication for GORD. eradication unless
Do not use clarithromycin, ulcer is complicated by
metronidazole or quinolone if used in haemorrhage or
past year for any infection. perforation.)
Penicillin allergy: use PPI +
clarithromycin & metronidazole. If PPI WITH Amoxicillin 1g BD
previous clarithromycin use PPI + or either clarithromycin 500mg BD
bismuth salt + metronidazole + OR metronidazole 400mg BD All for
Eradication of
tetracycline. 7 days
Helicobacter
Relapse and previous Penicillin allergy &
pylori
Seek specialist advice. previous clarithromycin
PPI WITH MALToma
Retest for H.pylori post DU/GU or bismuth subsalicylate 525mg QDS 14 days
relapse after second line therapy: metronidazole + 400mg BD
using breath or stool test OR tetracycline
consider endoscopy for culture & hydrochloride 500mg QDS
susceptibility.
Relapse & previous
Testing of H.pylori should not be Metronidazole +
performed within 4 weeks of Clarithromicin:
treatment with any antibiotic or 2 Seek specialist advice
weeks with any PPI as per NICE.
Fluid and electrolyte replacement is essential.
Antibiotic therapy is not usually indicated unless systemically unwell as it only reduces
diarrhoea by 1-2 days, can aggravate the disease and can lead to resistance.

If the patient remains systemically unwell initiate stool investigation for severe, prolonged or
recurrent diarrhoea, food poisoning or for travellers’ diarrhoea. Antibiotics may be indicated in:
- Severe / prolonged symptoms (>5 days);
- Systemic signs of infection;
- Suspected complications;
- Extremes of age;
- Immunocompromised hosts – discuss such cases with Microbiology.

If systemically unwell and Campylobacter suspected (e.g. undercooked meat and abdominal pain),
consider clarithromycin 250–500mg BD for 5–7 days, if treated early (within 3 days).3C
Infectious
Always consider referral to hospital if the patient is systemically unwell; has dehydration, jaundice, or
diarrhoea
abdominal pain; is on antibiotics or has had chemotherapy.

Refer children with severe or localised abdominal pain (this may suggest a surgical cause) or if they
have bloody diarrhoea (to investigate for E. coli 0157 infection) or if there are any red flag
symptoms or signs (https://www.nice.org.uk/guidance/cg84/chapter/1-Guidance#escalation-of-care).

Please notify suspected cases of food poisoning to the Public Health England North East and North
Central London Health Protection Team (NENCLHPT) 020 3837 7084. Send stool samples early in
these cases.

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 Duration of
ILLNESS COMMENTS DRUG ADULT DOSE
Treatment
GASTROINTESTINAL TRACT INFECTIONS CONTINUED

Stop unnecessary antibiotics and

1st and non-severe
PPIs; 70% respond to MTZ in 5 days;
episode:
92% in 14 days.

If severe symptoms or signs, i.e. 4 or

Antibiotic
more bowel movements per day for 2
related diarrhoea
or more days or presence of
e.g. Clostridium Metronidazole PO 400mg TDS 10-14 days
symptoms / signs below, treat with
difficile
oral vancomycin and/or hospital
referral.
Admit if severe: 2nd episode / severe:
T >38.5; WCC >15, rising creatinine
or signs/symptoms of severe colitis. Seek specialist advice
Only consider standby antibiotics when travelling to remote areas or people at high-risk of severe
illness with travellers’ diarrhoea
Travellers’
Diarrhoea If standby treatment appropriate give: *ciprofloxacin 500mg twice a day for 3 days (private
prescription). If quinolone resistance high (e.g. south Asia): consider bismuth subsalicylate (Pepto
Bismol) 2 tablets QDS as prophylaxis or for 2 days treatment
Treat all household contacts at the >6 months:
same time PLUS advise hygiene Mebendazole 100mg Stat
measures for 2 weeks (hand (off-label if <2yrs)
hygiene, pants at night, morning Repeat after 2
shower) PLUS wash sleepwear, bed weeks if
Threadworm
linen, dust, and vacuum on day one. Child < 6 months infestation
Mebendazole is persists
Child <6 months add perianal wet unlicensed, use
wiping or washes 3 hourly during hygiene measures
day. alone for six weeks
Evidence on the use of antibiotics for
the treatment of uncomplicated Co-amoxiclav 625mg TDS
diverticulitis is sparse, of low quality,
and conflicting. If allergic to penicillin 7 days
Mild, uncomplicated diverticulitis can
Acute
be managed at home with Ciprofloxacin and 500mg BD
Diverticulitis
paracetamol, clear fluids, and oral Metronidazole
(NICE CKS)
antibiotic

Prescribe broad-spectrum antibiotics

to cover anaerobes and Gram-
negative rods

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 URINARY TRACT INFECTIONS

For all UTI cases, please provide patients with the TARGET UTI leaflet. (Click on ‘Leaflets to share with patients’).

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1
See BNF for appropriate use and dosing in specific populations, for example, hepatic impairment and renal impairment, and administering intravenous antibiotics.
2
Check previous urine culture and susceptibility results and antibiotic prescribing and choose antibiotics accordingly.
3
The European Medicines Agency’s Pharmacovigilance Risk Assessment Committee has recommended restricting the use of fluoroquinolone antibiotics following a review of disabling and potentially
long-lasting side effects mainly involving muscles, tendons, bones and the nervous system (press release October 2018), but they are appropriate in acute prostatitis which is a severe infection.
4
Review treatment after 14 days and either stop or continue for a further 14 days if needed (based on history, symptoms, clinical examination, urine and blood tests).
5
Only consider when there is bacteriological evidence of sensitivity and good reasons to prefer this combination to a single antibiotic (BNF, August 2018).

When exercising
25 | P atheir
g ejudgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the
people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the
individual, in consultation with them and their families and carers or guardian.
26 | P a g e
 1 See BNF for appropriate use and dosing in specific populations, for example, hepatic
and renal impairment, and for administering intravenous antibiotics.
2 Check any previous urine culture and susceptibility results, and antibiotic prescribing,
and choose antibiotics accordingly.

1
See BNF for children (BNFC) for use and dosing in specific populations, for example, hepatic impairment and renal impairment, and for administering intravenous antibiotics. For
prescribing in pregnancy, refer to the table on
choice of antibiotic for pregnant women aged 12 and over.
2
Age bands apply to average size and, in practice, age bands will be used with other factors such as the severity of the condition and the child’s size.
3
Check any previous urine culture and susceptibility results, and antibiotic prescribing, and choose antibiotics accordingly. If a child or young person is receiving prophylactic
antibiotics, treatment should be with a different
antibiotic not a higher dose of the same antibiotic.
4
Low risk of resistance is likely if not used in the past 3 months, previous urine culture suggests susceptibility (but this was not used), and in areas where data suggests low
resistance. Higher risk of resistance is likely with recent use.
6
If intravenous treatment is not possible, consider intramuscular treatment, if suitable.
When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of
their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions
appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
27 | P a g e
When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of
their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions
appropriate to the circumstances of the individual, in consultation with them and their families and
carers or guardian.
1
See BNF for children (BNFC) for use and dosing in specific populations, for example, hepatic impairment and renal impairment, and for administering intravenous antibiotics. For
prescribing in pregnancy, refer to the table on
choice of antibiotic for pregnant women aged 12 and over.
2
Age bands apply to average size and, in practice, age bands will be used with other factors such as the severity of the condition and the child’s size.
3
Check any previous urine culture and susceptibility results, and antibiotic prescribing, and choose antibiotics accordingly. If a child or young person is receiving prophylactic
antibiotics, treatment should be with a different
antibiotic not a higher dose of the same antibiotic.
4
Low risk of resistance is likely if not used in the past 3 months, previous urine culture suggests susceptibility (but this was not used), and in areas where data suggests low
resistance. Higher risk of resistance is likely with recent use.
6
If intravenous treatment is not possible, consider intramuscular treatment, if suitable.
When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of
their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions
appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.

When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of
their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions
appropriate to 28
the|circumstances
Page of the individual, in consultation with them and their families and
carers or guardian.
29 | P a g e
1
See BNF for appropriate use and dosing in specific populations, for example, hepatic impairment, renal impairment and breast-feeding, and administering intravenous antibiotics
2
Check any previous urine culture, susceptibility and prescribing and choose antibiotics accordingly.
3
The European Medicines Agency’s Pharmacovigilance Risk Assessment Committee has recommended restricting the use of fluoroquinolone antibiotics following a review of
disabling and potentially long lasting side effects mainly involving muscles, tendons, bones and the nervous system (press release October 2018), but they are an option in acute
Pyelonephritis which is a severe infection.

When exercising 30their

| P judgement,
age professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their
patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to
the circumstances of the individual, in consultation with them and their families and carers or guardian.
1
See BNF for children (BNFC) for appropriate use and dosing in specific populations, for example hepatic and renal impairment, and administering intravenous antibiotics. If a
young women is pregnant, refer to the prescribing table on choice of antibiotic for pregnant women aged 12 years and over.
2
The age bands apply to children of average size and, in practice, the prescriber will use the age bands in conjunction with other factors such as the severity of the condition being
31child’s
treated and the | P a size
g e in relation to the average size of children of the same age.
3
Check any previous urine culture and susceptibility results and antibiotic prescribing and choose antibiotics accordingly.
32 | P a g e
33 | P a g e
 Duration of
ILLNESS COMMENTS DRUG ADULT DOSE
Treatment
GENITAL TRACT INFECTIONS
Contact UKTIS for information on foetal risks if patient is pregnant

STI screening People with risk factors should be screened for chlamydia, gonorrhoea, HIV, syphilis. Refer
individual and partners to GUM service who will advise on abstinence during treatment
period including partner notification and contact tracing.
(extra care would be Risk factors: <25yr, no condom use, recent (<12mth)/frequent change of partner, symptomatic
required in men) partner, area of high HIV.
Note: Chlamydia screening First Line
programme. Doxycycline 100 mg BD 7 days
(contraindicated in
Chlamydia Refer patients and contacts to pregnancy)
(Uncomplicated Sexual Health Clinic and other
urogenital, sexual health service providers. or
pharyngeal and #’rfew’;gf’#wg;#’wg.’#rw
rectal infections) / Azithromycin
g. 1g orally Stat
Opportunistically screen all aged
uretritis (If allergic
or or intolerant to
15-25 years.
Treat partners and refer to GUM tetracyclines and pregnant followed by
service. women )
500mg OD 2 days
As there are no data on the
effectiveness of the extended
course of azithromycin in the 10 to 14 days
treatment of rectal chlamydia, in or Erythromycin 500mg BD
individuals with rectal infection,
a Test Of Cure (TOC) is
recommended no earlier than 3
weeks after completion of or Ofloxacin 200mg BD 7 days
treatment. TOC continues to be (contraindicated in
recommended in pregnant pregnancy) 400mg OD 7 days
women.

Pregnant and
breastfeeding

Azithromycin Stat
1g orally

followed by
Daily for 2 days
500mg

500mg 4 times daily for

or Erythromycin
7 days

500mg Twice daily for

or Erythromycin 14 days

or Amoxicillin
500mg 3 times daily for
7 days
.
Please refer to BASHH
Guidelines available here

(Current Guidelines
>Urethritis and Cervicitis
>Chlamydia >Management).

34 | P a g e
Epididymitis For suspected epididymitis in
men over 35 years with low risk Ofloxacin 200mg BD 14 days
of STI (High risk, refer GUM). or Doxycycline 100mg BD 14 days

Gonorrhoea refer to GUM for culture/sensitivities

Syphilis refer to GUM for serology interpretation and assessment

500mg
All topical and oral azoles give
Clotrimazole pessary or stat
75% cure.
10% cream
or oral Fluconazole 150mg orally stat
Vaginal Candidiasis
In pregnancy: avoid oral azoles 100mg
and use intravaginal treatment Pregnant: Clotrimazole pessary at 6 nights
for 7 days. night
5g intravaginal
or Miconazole 2% cream 7 days
BD
Oral metronidazole (MTZ) is as
400mg BD 7 days
effective as topical treatment but Oral Metronidazole (MTZ)
or 2g stat
is cheaper.

Less relapse with 7 day than 2g

Bacterial Vaginosis stat at 4 weeks.
Pregnant/breastfeeding: avoid 5g applicator
or MTZ 0.75% vaginal gel 5 nights
2g stat. full at night
Treating partners does not 5g applicator
or Clindamycin 2% cream 7 nights
reduce relapse. full at night

35 | P a g e
 Duration of
ILLNESS COMMENTS DRUG ADULT DOSE
Treatment
GENITAL TRACT INFECTIONS CONTINUED
Treat partners and refer to GUM 400mg BD 5-7 days
Metronidazole (MTZ)
service. or 2g stat
In pregnancy or breastfeeding:
avoid 2g single dose MTZ. 100mg
Trichomoniasis
Consider clotrimazole for Clotrimazole pessary at 6 nights
symptom relief (not cure) if MTZ night
declined.

Test for chlamydia and N.

gonorrhoea. Avoid doxycycline Metronidazole PLUS 400mg BD 14 days
in pregnancy.
Ofloxacin 400mg BD 14 days
Refer woman and contacts to or Doxycycline 100mg BD
GUM service. Only treat if
sure of the absence of other If high risk of gonorrhoea
STIs. ADD Ceftriaxone 500mg IM Stat
If gonorrhoea likely (partner has
Mild Pelvic
it, sex abroad, severe
Inflammatory
symptoms), resistance to
Disease (PID)
quinolones is high, use
ceftriaxone regimen, or refer to
GUM.

Moderate – severe cases (fever,

clinical signs of tub-ovarian
abscess or signs of pelvic
peritonitis) should be urgently
referred to gynaecology.
MENINGITIS
Transfer all patients to IV or IM Benzylpenicillin Age 10+
hospital immediately. If time years: 1200mg
before hospital admission, and Children 1-9
non-blanching rash, give IV year: 600mg
Suspected benzylpenicillin or cefotaxime, or Children <1
meningococcal unless definite history of year: 300mg Stat
disease hypersensitivity
IV or IM Cefotaxime Age 12+
years: 1gram
Child < 12
Give IM if vein cannot be found years:
50mg/kg

Prevention of secondary case of meningitis: Only prescribe antibiotics following advice from the London Health Protection
Team

North East and North Central London Health Protection Team (NENCLHPT) contact numbers:

 Daytime Tel: 020 3837 7084

 For urgent notifications Out of Hours: Tel: 0207 191 1860
(between 5pm and 9am and during weekends and Bank Holidays)

36 | P a g e
 Duration of
ILLNESS COMMENTS DRUG ADULT DOSE
Treatment
SKIN INFECTIONS

Oral Flucloxacillin or 500mg QDS 7 days

For extensive, severe, or bullous if penicillin allergic,
impetigo, use oral antibiotics clarithromycin 250 –500mg 7 days
BD
Topical and oral treatment
produces similar results. As
resistance is increasing reserve
Impetigo
topical antibiotics for very
localised lesions.
Fusidic acid 2% cream or Topically TDS 5 days
Reserve Mupirocin for MRSA ointment.
advise good infection control
precautions MRSA only:
Mupirocin Topically TDS 5 days
If no visible signs of infection, use of antibiotics (alone or with steroids) encourages resistance
and does not improve healing
Eczema
In eczema with visible signs of infection, use treatment as in impetigo.

If patient afebrile and healthy

other than cellulitis, use oral Flucloxacillin 1g QDS All for 7 days.
flucloxacillin alone

Toxic appearance, admit If penicillin allergic:

If river or sea water exposure, Clarithromycin 500mg BD
discuss with microbiologist. If slow
If on statins: Doxycycline 200mg stat response
If febrile and ill, or comorbidity then 100mg continue for a
admit for IV treatment If unresolving: OD 300– further 7 days
Stop clindamycin if diarrhoea Clindamycin 450mg
occurs. (Caution with the use of QDS
Cellulitis clindamycin in >65, stop
Class I: patient afebrile and statin therapy whilst on
healthy other than cellulitis, use clindamycin)
oral flucloxacillin alone.
Class II febrile & ill, or
comorbidity, admit for If facial:
500/125mg
intravenous treatment, or use Co-amoxiclav
TDS
OPAT (if available).
Class III toxic appearance:
admit.1 If river or sea water
exposure, discuss with
specialist.

37 | P a g e
 Duration of
ILLNESS COMMENTS DRUG ADULT DOSE
Treatment

SKIN INFECTIONS continued

Diagnosis and management of the underlying condition is important. Routine swabs are not
recommended. But, If active infection, send pre-treatment swab. Review antibiotics after culture
results. Antibiotics are only indicated if significant cellulitis present. Selectively investigate
patients and treat those that do not resolve (see under cellulitis). Review the management of
diabetes in diabetic ulcers. ANTIBIOTICS DO NOT IMPROVE HEALING unless active
infection.

Active infection if cellulitis/increased pain/ pyrexia/ purulent exudate/ odour.

Leg Ulcers

500mg QDS 7 days

If active infection refer for Flucloxacillin
specialist advice if infection is or
500mg BD 7 days if slow
severe Clarithromycin
response,
continue for a
further 7 days.

Please seek advice from the local acute trust microbiology team for advice on prescribing
MRSA colonisation
eradication protocols and antibiotics for any confirmed MRSA infection.

MRSA Please see overleaf for the MRSA Decolonisation Protocol for Local Trusts (page 28).
Decolonisation

38 | P a g e
 MRSA Decolonisation Protocol

MRSA decolonisation is not routinely recommended for patients in the community unless clinically indicated. Conditions where MRSA eradication

may be considered include:

 Preparation for an elective procedure where patient is identified as positive for MRSA colonisation
 Management of a high-risk wound as advised by the microbiology/infection team
 Management of indwelling devices as advised by the microbiology/infection team

Where MRSA decolonisation has been recommended, please follow your local Trust guidelines. The topical regimens to be used can be found in the
guidelines listed in the table below.

Trust Decolonisation Regimen Comments

Bart’s Health NHS Please refer to full guidance on microguide APP Click on healthcare -
Trust http://microguide.horizonsp.co.uk/viewer/barts/adult associated infections
section then click MRSA

Please refer to full guidance on microguide

Barking,Havering and https://viewer.microguide.global/bhrhospitals/adult Click on healthcare -
Redbridge University associated infections
Trust section

Please refer to guidance on microguide See “Infection Prevention

Homerton University https://viewer.microguide.global/huh/adult and Control” section. Note:
Hospital NHSFT The Microguide contains the
in-patient decolonisation
protocol only. Liaise with
Infection Control to decide
appropriateness and
discuss if alternative
protocol required.

Advice on antibiotic treatment for clinically infected wounds in MRSA colonised patients can be obtained from the hospital microbiology
team.

For further information refer to each individual Trust guidelines.

39 | P a g e
 Duration of
ILLNESS COMMENTS DRUG ADULT DOSE
Treatment

SKIN INFECTIONS continued

Panton-Valentine Leukocidin (PVL) is a toxin produced by 4.9% of S. aureus from

PVL boils/abscesses. This bacteria can rarely cause severe invasive infections in healthy people; if
found suppression therapy should be given. Send swabs if recurrent boils/abscesses. At risk:
close contact in communities or sport; poor hygiene. See
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/322857/Guidanc
e_on_the_diagnosis_and_management_of_PVL_associated_SA_infections_in_England_2_Ed.
pdf

If positive PVL MRSA or positive S. aureus contact the North East and North Central
London Health Protection Team (NENCLHPT) contact numbers:

 Daytime Tel: 020 3837 7084

 For urgent notifications Out of Hours: Tel: 0207 191 1860
(between 5pm and 9am and during weekends and Bank
Holidays)

Thorough irrigation is important Prophylaxis or treatment:

Bites: Human Assess risk of tetanus, HIV, Co-amoxiclav 625mg TDS

7 days
hepatitis B&C

Antibiotic prophylaxis is advised

40 | P a g e
 Duration of
ILLNESS COMMENTS DRUG ADULT DOSE
Treatment

SKIN INFECTIONS continued

First line:
Assess risk of tetanus and
rabies Co-amoxiclav 625mg TDS

Give prophylaxis if cat

bite/puncture wound; bite to
hand, foot, face, joint, tendon, If penicillin allergic: 400mg TDS
ligament; Metronidazole PLUS 100mg BD All for 7 days
Bites: Cat or dog
immunocompromised/diabetic/ Doxycycline
asplenic/cirrhotic/ presence of (cat/dog/man)
prosthetic valve or prosthetic
joint

or Metronidazole 200-400mg
TDS
PLUS

Clarithromycin (human
bite) 250-500mg
AND review at BD
24&48hrs

Treat whole body from ear/chin

downwards and under nails. If
under 2 or elderly, also face/
scalp. Permethrin 5% cream
Itch can persist for weeks and
2 applications
Scabies antiprutitic cream or an oral
1 week apart
antihistamine may be indicated. If allergy: 0.5% aqueous
Treat all home and sexual Malathion liquid
contacts within 24 hours.
Please refer to local CCG guidelines in relation to the prescribing of over the counter
medications by GPs
Dermatophyte Terbinafine is fungicidal so Topical Terbinafine BD
infection – skin, treatment time shorter than with or topical Imidazole BD 1-2 weeks
foot and scalp fungistatic imidazoles. for 1-2 weeks
or (athlete’s foot only): after healing
If candida possible, use topical Undecanoates BD (i.e. 4-6weeks)
imidazole. (Mycota®)
If intractable: send skin
scrapings and if infection
confirmed, use oral
terbinafine/itraconazole.

Scalp: discuss with specialist,

oral therapy indicated.

41 | P a g e
 Duration of
ILLNESS COMMENTS DRUG ADULT DOSE
Treatment

SKIN INFECTIONS continued

Adults: Take nail clippings and First line: Terbinafine 250mg OD 6 – 12 weeks
start therapy only if infection is fingers 3 – 6 months
confirmed by laboratory toes
Oral terbinafine is more effective
than oral azole. Liver reactions Second line:
occur rarely with oral Itraconazole 200mg BD 7 days monthly
antifungals. 2 courses
Idiosyncratic liver reactions fingers 3 courses
occur rarely with terbinafine. toes
Third line for very
For children seek specialist superficial as limited
Dermatophyte advice evidence of
effectiveness: 1-2x/weekly 6 months
infection of the
Itraconazole (monitoring of liver Amorolfine 5% nail fingers 12 months
finger nail or toenail
function is recommended) lacquer. toes
Fingers -7 days
monthly (repeat
after 21 day
interval)
2 courses

Toes – 7 days
monthly (repeat
after 21 day
interval)
3 courses
Herpes Seek urgent specialist advice in
zoster/Varicella pregnant, immunocompromised
zoster/chicken and neonates.
pox/shingles
Chicken pox: IF onset of rash
<24hrs & >14 years or severe
pain or dense/oral rash or 2o
household case or steroids or
smoker consider aciclovir.
If indicated:
https://www.gov.uk/government/p
Aciclovir
ublications/viral-rash-in-pregnancy

Shingles: treat if >50 years and 800mg five

7 days
within 72 hours of rash (PHN times a day
rare if <50 years), or if active
ophthalmic or Ramsey Hunt or
eczema.

Seek advice from NENCLHPT

for immunoglobulin advice
Daytime Tel: 020 3837 7084
For urgent notifications Out of
Hours: Tel: 0207 191 1860
(between 5pm and 9am and
during weekends and Bank
Holidays) or e-mail:
[email protected]

Cold sores Cold sores resolve after 7–10d without treatment. Topical antivirals applied prodromally reduce
duration by 12-24hrs 1

42 | P a g e
 LYME DISEASE: laboratory investigations and diagnosis

43 | P a g e
 Table 1 Antibiotic treatment for Lyme disease in adults and young people (aged 12 and over) according to symptoms a

Symptoms Treatment First alternative Second alternative

Lyme disease without focal symptoms

Erythema migrans and/or Oral doxycycline: Oral amoxicillin: Oral azithromycinb:

Non-focal symptoms 100 mg twice per day or 200 mg once per day for 21 days 1 g 3 times per day for 21 days 500 mg daily for 17 days

Lyme disease with focal symptoms

Lyme disease affecting the cranial nerves or Oral doxycycline: Oral amoxicillin: –
peripheral nervous system 100 mg twice per day or 200 mg once per day for 21 days 1 g 3 times per day for 21 days

Lyme disease affecting the central nervous system Intravenous ceftriaxone: Oral doxycycline: –
2 g twice per day or 4 g once per day for 21 days (when an 200 mg twice per day or
oral switch is being considered, use doxycycline) 400 mg once per day for
21 days

Lyme disease arthritis Oral doxycycline: Oral amoxicillin: Intravenous ceftriaxone:

100 mg twice per day or 200 mg once per day for 28 days 1 g 3 times per day for 28 days 2 g once per day for
Acrodermatitis chronica atrophicans 28 days

Lyme carditisb Oral doxycycline: Intravenous ceftriaxone: –

100 mg twice per day or 200 mg once per day for 21 days 2 g once per day for 21 days

Lyme carditis and haemodynamically unstable Intravenous ceftriaxone: – –

2 g once per day for 21 days (when an oral switch is being
considered, use doxycycline)
a For Lyme disease suspected during pregnancy, use appropriate antibiotics for stage of pregnancy.
b Do not use azithromycin to treat people with cardiac abnormalities associated with Lyme disease because of its effect on QT interval.

44 | P a g e
 Table 2 Antibiotic treatment for Lyme disease in children (under 12) according to symptoms a, b, c

Symptoms Age Treatment First alternative Second alternative

Lyme disease without focal symptoms

Erythema migrans and/or 9–12 Oral doxycyclinea for children under 45 kg: Oral amoxicillin for children 33 kg and under: Oral azithromycind, e for
Non-focal symptoms years 5 mg/kg in 2 divided doses on day 1 followed 30 mg/kg 3 times per day for 21 days children 50 kg and under:
by 2.5 mg/kg daily in 1 or 2 divided doses for 10 mg/kg daily for 17 days
a total of 21 days
For severe infections, up to 5 mg/kg daily for
21 days

Under Oral amoxicillin for children 33 kg and under: Oral azithromycind, e for children 50 kg and –
9 30 mg/kg 3 times per day for 21 days under:
10 mg/kg daily for 17 days

Lyme disease with focal symptoms

Lyme disease affecting the cranial nerves 9–12 Oral doxycyclinea for children under 45 kg: Oral amoxicillin for children 33 kg and under: –
or peripheral nervous system years 5 mg/kg in 2 divided doses on day 1 followed 30 mg/kg 3 times per day for 21 days
by 2.5 mg/kg daily in 1 or 2 divided doses for
a total of 21 days
For severe infections, up to 5 mg/kg daily for
21 days

Under Oral amoxicillin for children 33 kg and under: – –

9 30 mg/kg 3 times per day for 21 days

9–12 Intravenous ceftriaxone for children 50 kg Oral doxycyclinea for children under 45 kg: –
Lyme disease affecting the central years and under: 5 mg/kg in 2 divided doses on day 1 followed
nervous system 80 mg/kg once per day for 21 days by 2.5 mg/kg daily in 1 or 2 divided doses for
a total of 21 days
For severe infections, up to 5 mg/kg daily

45 | P a g e
 Under Intravenous ceftriaxone for children 50 kg – –
9 and under: 80 mg/kg once per day for
21 days

Lyme arthritis or 9–12 Oral doxycyclinea for children under 45 kg: Oral amoxicillin for children 33 kg and under: Intravenous ceftriaxone for
Acrodermatitis chronica atrophicans years 5 mg/kg in 2 divided doses on day 1 followed 30 mg/kg 3 times per day 28 days children 50 kg and under:
by 2.5 mg/kg daily in 1 or 2 divided doses for 80 mg/kg once per day for
a total of 28 days 28 days
For severe infections, up to 5 mg/kg daily for
21 days

Under Oral amoxicillin for children, 33 kg and Intravenous ceftriaxone for children 50 kg –
9 under: and under:
30 mg/kg 3 times per day for 28 days 80 mg/kg once per day for 28 days

Lyme carditis (both haemodynamically 9–12 Oral doxycyclinea for children under 45 kg: Intravenous ceftriaxone for children –
stable and unstable)e years 5 mg/kg in 2 divided doses on day 1 followed 50 kg and under:
by 2.5 mg/kg daily in 1 or 2 divided doses for 80 mg/kg once per day for 21 days
a total of 21 days
For severe infections, up to 5 mg/kg daily for
21 days

Under Intravenous ceftriaxone for children 50 kg – –

9 and under:
80 mg/kg once per day for 21 days
a At the time of publication (April 2018), doxycycline did not have a UK marketing authorisation for this indication in children under 12 years and is contraindicated. The use of
doxycycline for children aged 9 years and above in infections where doxycycline is considered first line in adult practice is accepted specialist practice. The prescriber should
follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's
Prescribing guidance: prescribing unlicensed medicines for further information.
b Discuss management of Lyme disease in children and young people with a specialist, unless they have a single erythema migrans lesion with no other symptoms, see

recommendation 1.3.2.
c Children weighing more than the amounts specified should be treated according to table 1.

46 | P a g e
dAt the time of publication (April 2018), azithromycin did not have a UK marketing authorisation for this indication in children under 12 years. The prescriber should follow
relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Prescribing
guidance: prescribing unlicensed medicines for further information.

eDo not use azithromycin to treat people with cardiac abnormalities associated with Lyme disease because of its effect on QT interval.
To find out why the committee made the recommendations on antibiotic treatment and how they might affect practice, see rationale and impact.

47 | P a g e
 Section 2: Information for patients

1. Refer to NHS Choices http://www.nhs.uk/Pages/HomePage.aspx

2. Treating your infection document: http://www.rcgp.org.uk/clinical-and-

research/target-antibiotics-
toolkit/~/media/2E1292605D174B318A5302223B04C175.ashx

3. Target UTI leaflet:

http://www.rcgp.org.uk/clinical-and-research/toolkits/target-antibiotic-toolkit.aspx

4. Get better without using antibiotics

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/24582 6/3-PC-Get-
well-soon-without-antibiotics1.pdf

5. Management of respiratory tract infections (coughs, colds, sore throats, and ear aches) in children
http://www.whenshouldiworry.com/

6. Home care is best poster for GP waiting area http://www.selfcareforum.org/wp-

content/uploads/2011/07/Poster_fin.pdf

7. Cough fact sheet

http://dev.selfcareforum.org/wp-content/uploads/2013/04/Cough_fin.pdf

8. Ear infection fact sheet

http://dev.selfcareforum.org/wp-content/uploads/2013/04/Ear_Infection_fin.pdf

9. Sore throat fact sheet

http://dev.selfcareforum.org/wp-content/uploads/2011/07/Sore_throat_fin.pdf

10. Use of antbiotics during pregnancy and risk of spontaneous abortion .Flory TM, Sheehy O, Berard A.
CMAJ. 2017 May; 1(189):625-633. Available from: http://www.cmaj.ca/content/189/17/E625

11. Antibiotic use in pregnancy – PHE management of infection guidance for primary care for
consultation and local adaptation
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/61274 3/
Managing_common_infections.pdf

12. PVL Staphylococcus aureus (Refer to page 24 of the link below for the patient leaflet)
https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachm
ent_data/file/322857/Guidance_on_the_diagnosis_and_management_of_PVL_assoc
iated_SA_infections_in_England_2_Ed.pdf

48 | P a g e
 Section 3: Notification of Infectious Diseases
Registered medical practitioners (RMPs) have a statutory duty to notify suspected cases of certain
infectious diseases (listed below).

These can be notified via their local health protection team (HPT). For North East and North Central
London, please contact Tel: 02038377084 (Fax: 020 3837 7086)

 Acute encephalitis
 Acute infectious hepatitis
 Acute meningitis
 Acute poliomyelitis
 Anthrax
 Botulism
 Brucellosis
 Cholera
 Diphtheria
 Enteric fever (typhoid or paratyphoid fever)
 Food poisoning
 Haemolytic uraemic syndrome (HUS)
 Infectious bloody diarrhoea
 Invasive group A streptococcal disease
 Legionnaires’ disease
 Leprosy
 Malaria
 Measles
 Meningococcal septicaemia
 Mumps
 Plague
 Rabies
 Rubella
 Severe Acute Respiratory Syndrome (SARS)
 Scarlet fever
 Smallpox
 Tetanus
 Tuberculosis
 Typhus
 Viral haemorrhagic fever (VHF)
 Whooping cough
 Yellow fever

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 References

1. Public Health England – Management of infection guidance for primary care for consultation and local
adaptation. Published June 2015- latest review April 2014.

2. Pneumonia: Diagnosis and management of community- and hospital-acquired pneumonia in adults. NICE Guideline
(CG191) December 2014

3. Dyspepsia and gastro-oesophageal reflux disease: Investigation and management of dyspepsia, symptoms
suggestive of gastro-oesophageal reflux disease, or both. NICE Guideline (CG184) September 2014

4. NICE Clinical Knowledge Summaries (CKS, formerly prodigy) available at https://cks.nice.org.uk/#?char=A

5. Royal College of General Practitioners Sexually Transmitted Infections

6. British Association for Sexual Health and HIV (BASHH) - Urethritis and Cervicitis, Chlamydia 2015 (Updated 26th
September 2018) https://www.bashh.org/guidelines

Useful Links
1. British Association of Dermatologists (BAD) guidelines available at http://www.bad.org.uk/healthcare-
professionals
2. Public Health England Main Web Site: https://www.gov.uk/government/organisations/public-health- england
3. http://legacytools.hpa.org.uk/AboutTheHPA/WhatTheAgencyDoes/LocalServices/NorthEastAndNorthCentr
alLondonHPT/
4. https://www.nice.org.uk/

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