to provide a simple, empirical approach to the treatment of common infections
to promote the safe, effective and economic use of antibiotics
to minimise the emergence of bacterial resistance in the community.
Principles of Treatment
This guidance is based on the best available evidence but its application should be modified by
professional judgement and patients should be involved in the decision.
Do not take a sensitivity report from the microbiology laboratory as an instruction to treat.
A dose and duration of treatment for adults is usually suggested, but may need modification for
age, weight and renal function. In severe or recurrent cases consider a larger dose or longer
Lower threshold for antibiotics in immune-compromised or those with multiple morbidities;
consider culture and seek advice.
Prescribe an antibiotic only when there is likely to be a clear clinical benefit.
Consider a no, or delayed, antibiotic strategy for acute sore throat, common cold, acute cough
and acute sinusitis, otitis media (patients > 2 years)
Do not prescribe an antibiotic for viral sore throat, or for simple coughs and colds.
Limit prescribing over the telephone to exceptional cases.
Use simple generic antibiotics first whenever possible.
The use of new and more expensive antibiotics (e.g. quinolones and cephalosporins) is
inappropriate when standard and less expensive antibiotics remain effective.
Avoid widespread use of topical antibiotics (especially those agents also available as systemic
In pregnancy AVOID tetracyclines, aminoglycosides, quinolones, and high dose metronidazole.
Short-term use of trimethoprim or nitrofurantoin is unlikely to cause problems to the foetus.
Clarithromycin is an acceptable alternative to erythromycin in those who are unable to tolerate the
latter because of side effects.
Where initial therapy has failed or special circumstances exist, microbiological advice can be
obtained from Dr Minassian or Dr Bentley at Northampton on 01604 545043 or 01604 545138
and Dr Manjula & Dr Rizkalla at Kettering on 01536 492697.
Pharyngitis / sore throat / tonsillitis CKS - acute sore throat
The majority of sore throats are viral, but there is clinical overlap between viral and streptococcal
infections. Antibiotics are unnecessary for most patients with sore throat as this is a self-limiting
condition, which resolves by one week in 85% of people, whether it is due to streptococcal infection
or not. The Centor criteria may be useful to predict patients who are at higher risk of GABHS and
complications, and who may benefit from antibiotics. The criteria are
History of fever
Tonsillar exudates
No cough
Tender anterior cervical lymphadenopathy
If 3 or 4 Centor criteria present consider 2 or 3 day delayed or immediate antibiotics.
Patients with more severe symptoms or history of otitis media may benefit more from antibiotics.
Antibiotics only shorten duration of symptoms by 8 hours. Antibiotics can prevent non-suppurative
complications of beta-haemolytic streptococcal pharyngitis but, in developed societies, such
complications are rare. You need to treat 30 children or 145 adults to prevent one case of otitis
media. Culture of Group A beta-haemolytic streptococcus (GABS) is inefficient as a diagnostic
criterion as it is too slow and it fails to differentiate between infection and carriage.
First line treatment
Phenoxymethylpenicillin 500mg qds for 10 days
First line treatment if allergic to penicillin
Erythromycin 250mg qds for 10 days
Otitis media (child doses) CKS - acute otitis media
Many are viral. 80% resolve without antibiotics. Poor outcome is more likely if the condition is
recurrent. Use paracetamol or NSAID. Antibiotics do not reduce pain in first 24 hours, subsequent
attacks or deafness. A GP needs to treat 20 children >2 years or 7 children 6-24 months old to get
pain relief in one child at 2-7 days.
First line treatment
<10 yrs; 250mg tds for 5 days
>10 yrs; 500mg tds for 5 days
First line treatment if allergic to penicillin
<2 yrs ; 125mg qds for 5 days
2-8 yrs ; 250mg qds for 5 days
>8 yrs ; 500mg qds for 5 days
Rhinosinusitis - acute on chronic CKS - sinusitis
Many are viral. Symptomatic benefit of antibiotics is small - 69% resolve without antibiotics; 84%
resolve with antibiotics. Reserve antibiotics for severe or persistent symptoms (>10 days).
First line treatments
Phenoxymethylpenicillin 500mg qds for 7 days
Amoxicillin 500mg tds for 7 days
Doxycycline 200mg stat/100mg od for 7 days
Acute bronchitis NICE CG 69 CKS - acute bronchitis
Systematic reviews indicate benefits of antibiotics are marginal in otherwise healthy adults.
First line treatments
Amoxicillin 500mg tds for 5 days
Erythromycin 500mg qds for 5 days
Doxycycline 200mg stat/100mg od for 5 days
Acute exacerbation of COPD NICE CG 101 - COPD
Remember - only 50% are caused by bacterial infection. Antibiotics are indicated if 2 or more of
cough, production of purulent sputum or breathlessness are present.
First line treatments
Amoxicillin 500mg tds for 5 days
Erythromycin 500mg qds for 5 days
Doxycycline 200mg stat/100mg od for 5 days
Second line treatment
Co-amoxiclav 500/125mg tds for 5 days
Community-acquired pneumonia (treatment in the community)
Antibiotics should be started immediately. If there is no response within 48 hours consider admission.
Most pneumonias are caused by Streptococcus pneumoniae sensitive to amoxycillin. Erythromycin is
used for the treatment of Mycoplasma pneumoniae, Legionella pneumophila and to cover Staph.
aureus – only 5% of mycoplasma infections occur in patients over 65 yrs of age; enquire regarding
risk factors for Legionella and Staph. aureus if severely ill and consider admission.
First line treatment
Amoxicillin 500mg tds for 7- 10 days
consider the addition of Erythromycin 500mg qds for 7-10 days if
patient is 65 years of age or older or they are confused, has an
increased respiratory rate >30/min or reduced BP (systolic < 90 or
diastolic < 60). If they have any these signs and are 65 years of age or
older, or a younger patients with 2 of these signs, consider referral to
First line treatment if allergic to penicillin
or intolerant of erythromycin
Doxycycline 200mg stat/100mg od for 7-10 days
The currently available quinolones have poor activity against pneumococci. However, they do have
use in PROVEN pseudomonal infections.
Suspected meningococcal disease
Transfer patient to hospital immediately.
First line treatment
adults and children 10yrs and over – 1.2G
children 1-9yrs – 600mg
children <1yr – 300mg
Administer benzylpenicillin prior to admission unless there is a history of anaphylactic reaction to
penicillin. Benzylpenicillin should be given IV but can be given IM if a vein cannot be found.
For the prevention of secondary cases of meningitis only prescribe following advice from the Health
Protection Agency.
UTI accounts for 1-3% of GP consultations in the UK and affects half of all women at some time
during their life. Sexually active women aged 20-50, pregnant women, the elderly, diabetics and
young girls are particularly susceptible to UTI. Prostatic enlargement in older men may cause
obstruction of the urinary tract, thereby increasing the risk of infection. UTI is most commonly caused
by coliforms (including E. coli) - 83%, Enterococcus sp. - 10%, Staph. epidermidis or S. saprophyticus
- 3%, and Pseudomonas sp. - 3%.
Management of simple UTI HPA QRG All non-pregnant women with symptoms of UTI (dysuria,
frequency, urgency or nocturia) should have an early morning MSU tested using a multi-test dipstick.
The four principal analytes are:Nitrite - bacteria reduce dietary nitrates to nitrites.
Leucocyte-esterase - enzyme present in white blood cells.
Protein and Blood - while these tests have very low sensitivity and specificity on their own they are
useful in that they contribute to the overall predictive value of a negative result.
The predictive value of a negative test, i.e. when all 4 indicators are negative, is very high - in patients
with a negative urine dipstick other causes of the patient’s symptoms should be considered e.g.
Candida or Chlamydia. The ability of the multi-test dipstick to predict positive results is lower. In nonpregnant women with clear symptoms of UTI the positive dipstick tests can be seen as confirmation
of infection and antibiotic therapy can be started.
Women CKS - uti lower women
First line treatments
Trimethoprim 200mg bd for 3 days (women)
Nitrofurantoin 50mg qds for 3 days (women)
Elderly women - Clinical symptoms may be less specific e.g. fever, anorexia or confusion; in addition
20% of elderly women may have asymptomatic bacteriuria. Therefore the diagnosis requires both
bacteriological evidence and careful clinical judgement. Catheterised patients will almost certainly
have bacteriuria; antibiotic therapy will not eradicate this and will select resistant organisms.
Men CKS - uti lower men
It is wise to consider the possibility of chlamydial urethritis in younger men. Symptomatic older men
should be investigated for prostatic hypertrophy.
First line treatments
Trimethoprim 200mg bd for 7 days
Nitrofurantoin 50mg qds for 7 days
Management of complicated UTI
A complicated UTI is one occurring in pregnant women, children, men or the elderly, or one that
either recurs or ascends to the upper tract. The latter produces symptoms such as fever, nausea,
malaise or loin pain. All patients with complicated UTI should have an MSU sent for MC&S and
treatment should be based on the results. In general, treatment of complicated UTI should be for 7
Acute pyelonephritis CKS - acute pyelonephritis :–
First line treatments
Ciprofloxacin 500mg bd for 7 days (ensure patient is not at risk of
C dificile)
Trimethoprim 200mg bd for 14 days
Consider referral if no response within 48 hours.
Pregnant women HPA QRG CKS - uti lower women :- An MSU should be sent if symptoms of UTI
First line treatments
Nitrofurantoin 50mg qds
Trimethoprim 200mg bd (off-label). Give folic acid in 1 st trimester
Cefalexin 500mg bd
If cultures remain positive after treatment or symptoms recur then seek advice regarding prophylaxis
for the remainder of pregnancy. Pregnant women with signs of acute pyelonephritis should be
referred to hospital. This is more likely to occur in women with a history of UTI, diabetes or chronic
renal impairment.
Children HPA QRG CKS - uti children - The information gained from multi-test dipstick on a carefully
taken urine sample can be used to judge whether antibiotic therapy.
First line treatments
Trimethoprim – see BNF for dosage
Nitrofurantoin – see BNF for dosage.
A specimen should always be sent for MC&S and therapy adjusted on the basis of sensitivity results.
Children should be referred for further investigation following their first proven UTI
Helicobacter pylori
Diagnosis is via faecal antigen in patients with relevant symptoms.
First line treatments
Lansoprazole 30mg bd PLUS
Clarithromycin 500mg bd PLUS
Amoxicillin 1g bd
Lansoprazole 30mg bd PLUS
Clarithromycin 250mg bd PLUS
Metronidazole 400mg bd
Triple or quadruple treatment attain >85% eradication. As resistance is
increasing, avoid Clarithromycin or Metronidazole if used in the
previous year for any infection. In treatment failure consider endoscopy
for culture & sensitivities.
Second line treatment
Lansoprazole 30mg bd PLUS
Bismuth (DE-NOL) 240mg bd PLUS
Two antibiotics from:
Amoxicillin 1g bd
Metronidazole 400mg tds
Oxytetracycline 500mg qds
Clostridium difficile associated diarrhoea
See separate policy.
Fluid replacement is essential. Antibiotic therapy is not usually indicated as it only reduces diarrhoea
by 1-2 days and can cause resistance. Initiate treatment, on the advice of a microbiologist, if the
patient is systemically unwell. Please notify suspected cases of food poisoning to, and seek advice on
exclusion of patients from the Public Health Doctor. Send stool samples in these cases.
Vaginal candidiasis CKS - vaginal candidiasis
All topical and oral azoles give 80-95% cure.
First line treatments
Clotrimazole 10% vaginal cream or 500mg pessary
Fluconazole 150mg tablet
Note - In pregnancy avoid oral azoles.
Bacterial vaginosis HPA CKS - bacterial vaginosis
First line treatments
Metronidazole 400mg bd for 7 days (this is slightly more effective than
Metronidazole 2g stat. The high dose should be avoided in pregnancy.
Metronidazole 0.75% vaginal gel 5g at night for 5 nights
Clindamycin 2% cream 5g at night for 7 nights.
Chlamydia trachomatis HPA CKS - chlamydia
First line treatments
Azithromycin 1g stat (1hr before or 2hrs after food). Azithromycin is
expensive but compliance is higher. Patients with positive chlamydia
swabs should be referred to a GUM clinic for screening for other STDs,
contact tracing and partner treatment.
Doxycycline 100mg bd for 7 days
Trichomoniasis HPA CKS - trichomoniasis
Treat partners simultaneously
First line treatments
Metronidazole 400mg bd for 5 -7days or 2g stat.
Note - The high dose should be avoided in pregnancy.
Clotrimazole 100mg pessaries for 6 days
Topical clotrimazole can be used for symptomatic relief (not cure).
Pelvic inflammatory disease RCOG CKS - pid
Ensure specimens for chlamydia and gonorrhoea are taken.
First line treatments
Ofloxacin 400mg bd PLUS Metronidazole 400mg bd for 14 days
Doxycycline 100mg bd PLUS Metronidazole 400mg bd for 14 days
PLUS Cefixime 400mg STAT.
Contacts should be referred to a GUM clinic.
Acute Prostatitis CKS - prostatitis
First line treatments
Ciprofloxacin 500mg bd 28 days (ensure patient is not at risk of
C dificile)
Trimethoprim 200mg bd should be used for 28 days
Impetigo CKS - impetigo
First line treatment
Flucloxacillin 500mg qds for 7 days
First line treatment if allergic to penicillin
Clarithromycin 250-500mg bd for 7 days.
Cellulitis CKS - acute cellulitis
If patient is afebrile and healthy apart from cellulitis
First line treatment
Flucloxacillin 500mg qds for 7-14 days
First line treatments if allergic to penicillin
Clarithromycin 500mg bd for 7-14 days
Clindamycin 300mg- 450mg qds for 7-14 days. (Discontinue
Clindamycin treatment immediately if diarrhoea develops).
Facial cellulitis
Co-amoxiclav 500/125mg tds for 7-14 days.
If patient is febrile and ill admit to hospital for IV treatment
Bites CKS - bites human and animal
For the prophylaxis and treatment of human or animal bites. In the management of bites surgical
cleaning is most important. The tetanus and rabies risks must always be assessed. Antibiotics should
be used prophylactically in bites over 24hrs old, cat bites and human bites, bites to the hand and in
at-risk patients e.g. diabetics and the elderly.
First line treatment
Co-amoxiclav 500/125mg tds for 7 days
First line treatment if allergic to penicillin
Metronidazole 200-400mg tds 7days PLUS Doxycycline 100mg bd 7
For human bites the hepatitis B and HIV risks must be assessed.
Conjunctivitis CKS - infective conjunctivitis
Bacterial conjunctivitis is usually begins unilaterally with a yellow/white mucopurulent discharge.
First line treatments
Chloramphenicol 0.5% eyedrops (every 2hours reducing to every 4
hours) and 1% ointment at night.
Fusidic acid 1% gel every 12hours. (easier to use but has less activity
against Gram-negative pathogens e.g. Haemophilus influenzae
Treatment should be used for 48 hours after resolution of symptoms. Other pathogens requiring
different and specific treatment include chlamydia, gonococcus and pseudomonas.
Dermatophyte infection of the nails CKS - fungal nail infection
Take nail-clippings and start therapy only if the laboratory confirms infection.
First line treatments
Terbinafine 250mg od should be used for 6-12 weeks for fingernail
infections and for 3-6 months for toenail infections.
Yeast and non-dermatophyte mould infections pulsed Itraconazole can
be used. The dose is 200mg bd for 7 days on/21 days off for 2 months
for fingernail infections and for 3 months for toenail infections.
Before treating children seek advice.
Dermatophyte infection of the skin CKS body & groin CKS foot CKS scalp
First line treatments
A topical Clotrimazole 1% cream once or twice daily for 4-6 weeks.
If this fails consider topical Terbinafine 1% cream once or twice daily
for 1-2 weeks.
For intractable cases consider oral Itraconazole 200mg once or twice
daily for 7 days
Methicillin resistant Staph. aureus (MRSA)
Treat only when there is clinical evidence of infection and not purely on laboratory results. Where oral
therapy is required please discuss with Microbiologist.
Chicken pox and shingles CKS - chickenpox
The clinical value of antivirals is minimal unless the patient is an adolescent or adult who is a
secondary household case of chickenpox or a patient with facial or ophthalmic shingles or has
shingles with severe pain. Treatment should be started within 24 hours of the onset of the rash.
First line treatment
Adult - 800mg 5x/day for 7 days
Children - see the BNF
Second line treatment only if compliance
a problem (ten times the cost)
Valaciclovir 1g tds for 7 days
Predictors of post-herpetic neuralgia include age >50yrs, severe pain, severe skin rash and prolonged
prodromal pain.
Please seek advice regarding chickenpox in pregnancy.
Guidance based on “HPA Management of Infection Guidance For Primary Care For Consultation +
Local Adaptation (March –July 2010)”
Consultant Microbiologists at NGH & KGH.
August 2010
Northamptonshire Prescribing Management Group