MANAGEMENT OF INFECTION GUIDANCE FOR PRIMARY CARE SUMMARY

ILLNESS/COMMENTS

DRUG

DOSE

DURATION

UPPER RESPIRATORY TRACT INFECTIONS

INFLUENZA:Annual vaccination 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 within 48 hours of onset or in a care home where influenza is
likely. At risk: pregnant (including up to two weeks post partum), 65 yrs, chronic respiratory disease (including COPD and asthma),
significant CV disease (not hypertension), immunocompromised, diabetes mellitus, chronic neurological, renal or liver disease. Use 5 days
treatment with oseltamivir 75 mg bd unless pregnant or if there is resistance to oseltamivir, use 5 days zanamivir 10 mg BD (2 inhalations
by diskhaler) and seek advice. For prophylaxis, see NICE. (NICE Influenza). Patients under 13 years see HPA Influenza link.
phenoxymethylpenicillin
500 mg QDS/1G BD (QDS
10 days
ACUTE SORE THROAT: Avoid ABx as
when severe)
90% resolve in 7 days without, and pain only
reduced by 16 hours. RCT in <18yr olds shows
Penicillin Allergy:
10d had lower relapse. Antibiotics to prevent
250-500mg BD
Clarithromycin
5 days
Quinsy NNT >4000 Antibiotics to prevent
If Centor score 3 or 4: (Lymphadenopathy; No Cough; Fever; Tonsillar Exudate) consider 2 or
Otitis media NNT 200.
3-day delayed or immediate antibiotics or rapid antigen test.
ACUTE OTITIS MEDIA (child doses):
Optimise analgesia and target ABx.OM resolves in
60% in 24 h without ABx, which only reduce pain at 2
days and does not prevent deafness.Consider 2 or 3day delayed or immediate antibiotics for pain relief if:
<2 years AND bilateral AOM (NNT4) or bulging
membrane & 4 marked symptoms
All ages with otorrhoea NNT3
Abx to prevent Mastoiditis NNT >4000
ACUTE OTITIS EXTERNA:First use aural
toilet (if available) & analgesia. Cure rates similar
at 7 days for topical acetic acid or antibiotic +/steroid. If cellulitis or disease extending outside
ear canal, start oral antibiotics and refer
ACUTE RHINOSINUSITIS: Avoid ABx
as 80% resolve in 14 days without, and they
only offer marginal benefit after 7 days. Use
adequate analgesia. Consider 7-day delayed or
immediate antibiotic when purulent nasal
discharge .In persistent infection use an agent
with anti-anaerobic activity eg. co-amoxiclav

amoxicillin
Penicillin Allergy:
erythromycin

First Line:
acetic acid 2%
Second Line:
neomycin sulphate with
corticosteroid
amoxicillin
or doxycycline
or phenoxymethylpenicillin

Child doses:
40mg/kg/day in 3 doses (max.
1.5g daily)

5 days

< 2yrs 125mg QDS

2-8yrs 250mg QDS
8-18yrs 250-500mg QDS

1 spray TDS

5 days

7 days

3 drops TDS
500mg TDS
1g if severe
200mg stat/100mg OD
500mg QDS

7 days min to
14 days max
7 days
7 days
7 days

For persistent symptoms:

co-amoxiclav
625mg TDS
7 days
LOWER RESPIRATORY TRACT INFECTIONS: Note: Low doses of penicillins more likely to select out resistance, Do
not use quinolone (ciprofloxacin, ofloxacin) first line due to poor pneumococcal activity. Reserve all quinolones (including
levofloxacin) for proven resistant organisms.

ACUTE COUGH, BRONCHITIS: AB little benefit if no co-morbidity.

amoxicillin
Consider 7d delayed AB with advice. Symptom resolution can take 3 weeks.
Consider immediate ABx if > 80yr and ONE of: hospitalisation in past year,
or
oral steroids, diabetic, congestive HF
OR> 65yrs with 2 of above
doxycycline
amoxicillin
ACUTE EXACERBATION OF COPD: Treat exacerbations
promptly with ABx if purulent sputum and increased shortness
or doxycycline
of breath and/or increased sputum volume . Risk factors for AB
or clarithromycin
resistant organisms include co-morbid disease, severe COPD,
If resistance:
frequent exacerbations, antibiotics in last 3m
co-amoxiclav
COMMUNITY ACQUIRED
PNEUMONIA - Tx in the community
Use CRB65 score to help guide and review:
Each scores 1: Confusion (AMT<8);
Respiratory rate >30/min; Age >65;
BP systolic <90 or diastolic 60;
Score 0: suitable for home treatment;
Score 1-2: hospital assessment or admission
Score 3-4: urgent hospital admission
Mycoplasma infection is rare in over 65s

500 mg TDS

5 days

ILLNESS/COMMENTS

DRUG

DOSE

MENINGITIS (NICE fever guidelines) *Transfer all patients to hospital immediately*

IV or IM benzylpenicillin
Age 10+ years: 1200 mg
SUSPECTED MENINGOCOCCAL DISEASE :
Children 1 - 9 yr: 600 mg
*Transfer all patients to hospital immediately*
or
Children <1 yr: 300 mg
If time before admission, and non-blanching rash, give IV
benzylpenicillin or cefotaxime,unless definite history of
IV or IM cefotaxime
Age 12+ years: 1gram
hypersensitivity

DURATION

(give IM if
vein cannot
be found)

Child < 12 yrs: 50mg/kg

Prevention of 20 case of meningitis: Only prescribe following advice from Public Health Doctor:refer to signposting document

URINARY TRACT INFECTIONS (refer to HPA UTI guidance for diagnosis information): People > 65 years: do not

treat asymptomatic bacteriuria; it is common but is not associated with increased morbidity. Catheter in situ: ABx will not
eradicate asymptomatic bacteriuria; only treat if systemically unwell or pyelonephritis likely . Do not use prophylactic ABx for
catheter changes unless history of catheter-change-associated UTI or trauma (NICE & SIGN guidance).

Women all ages

trimethoprim
200mg BD
UTI IN ADULTS (no fever or flank pain):
3 days
or nitrofurantoin
100mg m/r BD
Women severe/or 3 symptoms: treat. Women
Men 7 days
mild/or 2 symptoms: use dipstick and presence of
Second line: perform culture in all treatment failures
cloudy urine to guide Tx. Nitrite & blood/leucocytes
Amoxicillin resistance is common; only use if susceptible
has 92% PPV; -ve nitrite, leucocytes, and blood has a
Community multi-resistant Extended-spectrum Beta-lactamase E. coli are
76% NPV. Men: Consider prostatitis & send preincreasing: consider nitrofurantoin (or fosfomycin 3g stat in women plus 2nd 3g
treatment MSU OR if symptoms mild/non-specific,
dose in men 3 days later), on advice of microbiologist
use ve dipstick to exclude UTI.
ciprofloxacin
500mg BD
28 days
ACUTE PROSTATITIS: Send MSU for culture & start
ABx.4-wk course may prevent chronic prostatitis.
or ofloxacin
200mg BD
28 days
Quinolones achieve higher prostate levels.
2nd line: trimethoprim
200mg BD
28 days
UTI IN PREGNANCY : Send MSU for culture
and start ABx. Short-term use of nitrofurantoin in
pregnancy unlikely to cause problems to foetus.
Avoid trimethoprim if low folate status or on folate
antagonist (eg antiepileptic or proguanil).

First line: nitrofurantoin

if susceptible: amoxicillin
Second line: trimethoprim
Give folate if 1st trimester
Third line: cefalexin

100 mg m/r BD
500 mg TDS
200 mg BD (off-label)

All for 7 days

500 mg BD

Lower UTI: trimethoprim or nitrofurantoin

Lower UTI
UTI IN CHILDREN: Child <3 mths: refer urgently for
if susceptible: amoxicillin Second line: cefalexin
3 days
assessment. Child 3 months: use positive nitrite to start ABx.
Upper UTI
Send pre-treatment MSU for all. Refer to BNF for dosage.
Upper UTI: co-amoxiclav Second line: cefixime
7-10 days
Imaging: only refer if child <6 months, recurrent or atypical UTI.
ciprofloxacin
500 mg BD
7 days
ACUTE PYELONEPHRITIS: If admission not needed, send MSU for
culture & sensitivities and start ABx. If no response within 24 hrs, admit
or co-amoxiclav
500/125 mg TDS
14 days
Antibiotics:
Post coital stat
RECURRENT UTI IN NON-PREGNANT WOMEN
nitrofurantoin
50100 mg
(off-label)
3 UTIs/year: Cranberry products OR Post-coital OR
or trimethoprim
100 mg
Prophylaxis OD
standby ABx may reduce recurrence.
Nightly: reduces UTIs but adverse effects.
at night

GASTRO-INTESTINAL TRACT INFECTIONS

IF CRB65=0: amoxicillin
or clarithromycin
or doxycycline

625 mg TDS
500 mg TDS
500 mg BD
200 mg stat/100mg OD

If CRB65=1 & AT HOME

amoxicillin
AND clarithromycin

500 mg TDS
500 mg BD

7-10 days

Drugs fully absorbed (fluconazole, ketoconazole and itraconazole) and partially

ORAL CANDIDIASIS: Antifungal agents
absorbed (miconazole and clotrimazole) are effective compared with placebo or
absorbed from the gastrointestinal tract prevent oral
no treatment. See BNF for licensed dosage.
candidiasis in patients receiving treatment for cancer.
First line: PPI (use cheapest) PLUS
TWICE DAILY
ERADICATION OF HELICOBACTER
clarithromycin (C)
250 mg BD with MTZ
All for
PYLORI: Eradication is beneficial in known
AND
500mg BD with AM
7 days
DU, GU or low grade MALToma. Consider test
and treat in persistent uninvestigated
metronidazole (MTZ) or
400 mg BD
dyspepsia. Do not offer eradication for GORD.
amoxicillin (AM)
1g BD
Relapse
Do not use clarithromycin or metronidazole if
2nd line: PPI PLUS
TWICE DAILY
or MALToma
used in the past year for any infection. DU/GU
bismuthate (De-nol tab)
120 mg QDS
14 days
relapse: retest for H. pylori using breath or
PLUS 2 unused antibiotics:
stool test OR consider endoscopy for culture &
amoxicillin
1 g BD
susceptibility.
metronidazole
400 mg TDS
NUD: Do not retest, offer PPI or H2RA.

or doxycycline alone

200 mg stat/100mg OD

7-10 days

infection. AB therapy not indicated unless systemically unwell. If systemically unwell and campylobacter suspected (e.g. undercooked
meat and abdominal pain), consider clarithromycin 250500 mg BD for 57 days if treated early.

200 mg stat/100 mg OD
500 mg TDS
200 mg stat/100 mg OD
500 mg BD

5 days
5 days
5 days
5 days
5 days
7 days
7 days
7 days

tetracycline
500 mg QDS
INFECTIOUS DIARRHOEA: Refer previously healthy children with acute painful or bloody diarrhoea to exclude E. coli 0157

Doses are oral and for adults unless otherwise stated. Refer to BNF for further information or links on full HPA guidance (=child doses):.
Summarised on behalf of Prescribing Clinical Network (PCN) from Health protection Agency template October 2013 refer to PAD for related documents
HPA template Last Reviewed Nov 2012
Page 1 of 2

Next Review: November 2014

MANAGEMENT OF INFECTION GUIDANCE FOR PRIMARY CARE SUMMARY

ILLNESS/COMMENTS

DRUG

DOSE

DURATION

GASTRO-INTESTINAL TRACT INFECTIONS contd

CLOSTRIDIUM DIFFICILE: .If severe symptoms or signs
(below) should treat with oral vancomycin, review progress closely
and/or consider hospital referral.
Admit if severe: T >38.5; WCC >15, rising creatinine or
signs/symptoms of severe colitis,

1st/2nd episodes
metronidazole (MTZ)
3rd episode/severe/type 027
oral vancomycin

400mg TDS

10-14 days

125mg QDS

10 -14 days

Stop unnecessary ABx and/or PPIs.70% respond to MTZ in 5days;

92% in 14days

TRAVELLERS DIARRHOEA:Only consider standby antibiotics for remote areas or people at high-risk of severe illness with travellers
diarrhoea.If standby treatment appropriate give: ciprofloxacin 500 mg twice a day for 3 days (private Rx). If quinolone resistance high (eg
south Asia): consider bismuth subsalicylate (Pepto Bismol) 2 tablets QDS as prophylaxis or for 2 days treatment..
>6 months: mebendazole (off100 mg
stat
THREADWORM: Treat all household contacts at
the same time PLUS advise hygiene measures for 2
label if <2yrs)
weeks (hand hygiene, pants at night, morning
3-6 mths: piperazine+senna
2.5ml spoonful
stat, repeat after 2
shower) PLUS wash sleepwear, bed linen, dust,
weeks
< 3mths: 6 wks hygiene
and vacuum on day one.

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. Risk factors: < 25y, no condom use, recent (<12mth)/frequent change of partner, symptomatic partner.
azithromycin
1g
stat
CHLAMYDIA TRACHOMATIS / URETHRITIS: Screen
opportunistically all aged 15-25yrs. . Tx partners and refer to GUM
or doxycycline
100 mg BD
7 days
service
Pregnant or breastfeeding:
Pregnancy or breastfeeding: azithromycin most effective option.
azithromycin
1g (off-label use)
stat
Due to lower cure rate in pregnancy, test for cure 6 weeks after
or erythromycin
500 mg QDS
7 days
Tx.
or amoxicillin
500 mg TDS
7 days

For suspected epididymitis in men

ofloxacin
400 mg BD
or doxycycline
100mg BD
clotrimazole
500 mg pess or 10% cream
VAGINAL CANDIDIASIS: All topical
and oral azoles give 75% cure
or oral fluconazole
150 mg orally
In pregnancy: avoid oral azoles and use
clotrimazole
100 mg pessary at night
intravaginal treatment for 7 days
or miconazole 2% cream
5 g intravaginally BD
oral metronidazole (MTZ)
400 mg BD
BACTERIAL VAGINOSIS: Oral MTZ is as
effective as topical treatment but is cheaper.
or 2 g

14 days
14 days
stat
stat
6 nights
7 days
7 days
stat

Less relapse with 7 day than 2g stat at 4 wks.

or MTZ 0.75% vag gel
5 g applicatorful at night
5 night
Pregnant/breastfeeding: avoid 2g stat.
or clindamycin 2% crm
5 g applicatorful at night
7 nights
Treating partners does not reduce relapse .
metronidazole (MTZ)
400 mg BD
5-7 days
TRICHOMONIASIS: Tx partners and refer to GUM service.
In pregnancy or breastfeeding: avoid 2g single dose MTZ.
or 2 g
stat
Consider clotrimazole for symptom relief (not cure) if MTZ
declined.
clotrimazole
100 mg pessary at night
6 nights
PELVIC INFLAMMATORY DISEASE:Refer woman
& contacts to GUM service. Always culture for gonorrhoea
& chlamydia. 28% of gonorrhoea isolates now resistant to
quinolones. If gonorrhoea likely (partner has it, severe
symptoms, sex abroad) use ceftriaxone regimen or refer to
GUM.

metronidazole PLUS
ofloxacin
If high risk of GC
Ceftriaxone PLUS
Metronidazole PLUS
doxycycline

400 mg BD
400 mg BD

14 days
14 days

500 mg IM
400 mg BD
100 mg BD

Stat
14 days
14 days

SKIN INFECTIONS
IMPETIGO: For extensive, severe,
or bullous impetigo, use oral ABx.
Reserve topical ABx for very localised
lesions to reduce risk of resistance..
Reserve mupirocin for MRSA

oral flucloxacillin
If penicillin allergic
oral clarithromycin
topical fusidic acid
MRSA only mupirocin

ILLNESS/COMMENTS

DRUG

DOSE

DURATION

500 mg QDS

All for 7 days.

If slow response
continue for a
further 7 days

SKIN INFECTIONS contd

500 mg QDS

7 days

250-500 mg BD
TDS
TDS

7 days
5 days
5 days

ECZEMA:If no visible signs of infection, use of antibiotics (alone or with steroids) encourages resistance and does not improve healing.
In eczema with visible signs of infection, use treatment as in impetigo.
permethrin
5% cream
SCABIES: Tx all home & sexual contacts within
24h. Tx whole body from ear/chin downwards and
If allergy:
2 applications 1 week
under nails. If under 2/elderly, also face/scalp.
malathion
0.5% aqueous liquid
apart

CELLULITIS: If patient afebrile and healthy other

than cellulitis, use oral flucloxacillin alone. If river or sea
water exposure, discuss with microbiologist.
If febrile and ill, admit for IV treatment.
Stop clindamycin if diarrhoea occurs.
LEG ULCER : Ulcers always colonized. ABx do
not improve healing unless active infection.
If active infection, send pre-treatment swab.
Review ABx after culture results.
MRSA:For active MRSA infection:
Use AB sensitivities to guide Tx.If severe
infection or no response to monotherapy
after 24-48 hours, seek advice from
microbiologist on combination therapy.

flucloxacillin
If penicillin allergic:
clarithromycin
or clindamycin
facial: co-amoxiclav

500 mg BD
300450 mg QDS
500/125 mg TDS

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

If active infection:
flucloxacillin
or clarithromycin

500 mg QDS
500 mg BD

As for cellulitis

For MRSA screening and suppression see HPA MRSA quick reference guide. If active
infection, MRSA confirmed by lab results, infection not severe and admission not required

If active infection confirmed

Both for 7 days
doxycycline alone OR
100 mg BD
If diarrhoea, STOP
clindamycin alone
300450 mg QDS
Prophylaxis or treatment:
All for 7
BITES (human or animal): Thorough irrigation is
important. Assess risk of tetanus, HIV, hepatitis B&C
co-amoxiclav
375-625 mg TDS
days
Human: AB prophylaxis advised .Assess risk of
If penicillin allergic:
tetanus and rabies.
metronidazole PLUS
200-400 mg TDS
Cat or dog: Give prophylaxis if cat bite/puncture
doxycycline (cat/dog/man)
100 mg BD
wound; bite to hand, foot, face, joint, tendon,
or metronidazole PLUS
200-400 mg TDS
ligament; immunocompromised / diabetic/ asplenic/
clarithromycin (human bite)
250-500 mg BD
cirrhotic
AND review at 24&48hrs
Topical terbinafine
BD
1-2 weeks
DERMATOPHYTE INFECTION skin :
Terbinafine is fungicidal , so Tx time shorter than with
fungistatic imidazoles. If candida possible, use imidazole.
or topical imidazole
If intractable: send skin scrapings. If infection confirmed, use
or (athletes foot only):
oral terbinafine/itraconazole.
topical undecanoates (Mycota)
Scalp: discuss with specialist.
Superficial only:amorolfine
1-2x/weekly
DERMATOPHYTE INFECTION nail:Take
nail clippings: start therapy only if infection is
5% nail lacquer
confirmed by laboratory .Terbinafine is more
First line: terbinafine
250 mg OD
effective than azoles. Liver reactions rare with oral
antifungals. If candida or non-dermatophyte
Second line: itraconazole
200 mg BD
infection confirmed, use oral itraconazole.
For children, seek specialist advice .
VARICELLA ZOSTER / CHICKEN
POX:Pregnant/immunocompromised/neo
nate: seek urgent specialist advice.
Chicken pox:IF onset of rash <24h & >14y
or severe pain or dense/oral rash or 2o
household case or steroids or smoker
consider aciclovir.
HERPES ZOSTER/
SHINGLES: Shingles: treat if
>50 yrs and within 72 hrs of
rash (PHN rare if <50yrs); or if
active ophthalmic or Ramsey
Hunt or eczema.

If indicated:
aciclovir

Second line for shingles if compliance a

problem, as ten times cost
valaciclovir
or famciclovir
If indicated:
Acyclovir
Second line for shingles if compliance a problem,
as ten times cost
valaciclovir
or famciclovir

BD
BD
fingers
toes
fingers
toes
fingers
toes

for 1-2 wks after

healing
(i.e. 4-6wks)
6 months
12 months
6 12 weeks
3 6 months
7 days monthly
2 courses
3 courses

800 mg five times a day

7 days

1 g TDS
250 mg TDS

7 days
7 days

800 mg five times a day

7 days

1 g TDS
250 mg TDS

7 days
7 days

COLD SORES:Cold sores resolve after 710d without treatment. Topical antivirals applied prodromally reduce duration by 12-24hrs.

For additional recommendations for Eye and Dental Infections please refer either directly to the Health Protection Agency
(HPA)template (please note HPA is now part of Public Health England) or the Prescribing advisory database (PAD).For contact
details refer to signposting document (Available on the PAD).
Summarised on behalf of the PCN for the following Clinical Commissioning Groups (CCGs): Surrey Heath CCG, Surrey Downs
CCG, East Surrey CCG, Guildford & Waverley CCG, Crawley CCG, Horsham & Mid Sussex CCG & North West Surrey CCG

Doses are oral and for adults unless otherwise stated. Refer to BNF for further information or links on full HPA guidance (=child doses):.
Summarised on behalf of Prescribing Clinical Network (PCN) from Health protection Agency template October 2013 refer to PAD for related documents
HPA template Last Reviewed Nov 2012
Page 2 of 2

Next Review: November 2014