Summary of antimicrobial prescribing guidance – managing common infections

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

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

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

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

Summary of antimicrobial prescribing guidance – managing common infections (February 2019) 1

 Doses Visual
Infection Key points Medicine Length
Adult Child summary
Influenza Annual vaccination is essential for all those ‘at risk’ of influenza.1D Antivirals are not recommended for healthy adults.1D,2A+
Treat ‘at risk’ patients with 5 days oseltamivir 75mg BD,1D when influenza is circulating in the community, and ideally within 48 hours of onset (36 hours for
zanamivir treatment in children),1D,3D or in a care home where influenza is likely.1D,2A+
Public Health At risk: pregnant (and up to 2 weeks post-partum); children under 6 months; adults 65 years or older; chronic respiratory disease (including COPD and
England asthma); significant cardiovascular disease (not hypertension); severe immunosuppression; chronic neurological, renal or liver disease; diabetes mellitus;
morbid obesity (BMI>40).4D See the PHE Influenza guidance for the treatment of patients under 13 years.4D In severe immunosuppression, or oseltamivir
Last updated: resistance, use zanamivir 10mg BD5A+,6A+ (2 inhalations twice daily by diskhaler for up to 10 days) and seek advice.4D
Feb 2019
Access supporting evidence and rationales on the PHE website.
Scarlet fever Phenoxymethylpenicillin2D 500mg QDS2D 10 days3A+,4A+,5A+ Not available.
Prompt treatment with appropriate antibiotics
(GAS) Access
significantly reduces the risk of complications.1D
Public Health Penicillin allergy: 250mg to 500mg supporting
Vulnerable individuals (immunocompromised, the 5 days2D,5A+ evidence and
England clarithromycin2D BD2D
comorbid, or those with skin disease) are at rationales on the
Last updated: increased risk of developing complications.1D
Oct 2018
Optimise analgesia2D and give safety netting advice PHE website

Acute otitis Regular paracetamol or ibuprofen for pain (right First choice: amoxicillin 5–7 days
media dose for age or weight at the right time and Penicillin allergy:
maximum doses for severe pain). 5–7 days
clarithromycin OR
Otorrhoea or under 2 years with infection in erythromycin (preferred if
both ears: no, back-up or immediate antibiotic. 5–7 days
pregnant)
Otherwise: no or back-up antibiotic. Second choice: co- 5–7 days
Systemically very unwell or high risk of amoxiclav
complications: immediate antibiotic.
Last updated: Feb
2018 For detailed information click on the visual summary.
First line: analgesia for pain relief,1D,2D and apply Second line:
Acute otitis
localised heat (such as a warm flannel).2D topical acetic acid 2%2D,4B- 1 spray TDS5A- 7 days5A
externa
Second line: topical acetic acid or topical OR Not available.
antibiotic +/- steroid: similar cure at Access
Public Health topical neomycin sulphate 7 days (min) to supporting
7 days.2D,3A+,4B- 3 drops TDS5A-
England with corticosteroid2D,5A- 14 days (max)3A+ evidence and
If cellulitis or disease extends outside ear rationales on the
canal, or systemic signs of infection, start oral 250mg QDS2D PHE website
Last updated: flucloxacillin and refer to exclude malignant otitis If cellulitis: flucloxacillin6B+ If severe: 500mg 7 days2D
Nov 2017
externa.1D QDS2D

Summary of antimicrobial prescribing guidance – managing common infections (February 2019) 2

 Doses Visual
Infection Key points Medicine Length
Adult Child summary
Sinusitis First choice:
Advise paracetamol or ibuprofen for pain. Little 500mg QDS 5 days
phenoxymethylpenicillin
evidence that nasal saline or nasal
Penicillin allergy:
decongestants help, but people may want to try 200mg on day 1, then
doxycycline (not in under 5 days
them. 100mg OD
12s) OR
Symptoms for 10 days or less: no antibiotic.
clarithromycin OR 500mg BD 5 days
Symptoms with no improvement for more
erythromycin (preferred if 250 to 500mg QDS
than 10 days: no antibiotic or back-up antibiotic
pregnant) or 5 days
depending on likelihood of bacterial cause.
Consider high-dose nasal corticosteroid (if over 500 to 1000mg BD
12 years). Second choice or first
Systemically very unwell or high risk of choice if systemically
complications: immediate antibiotic. very unwell or high risk of 500/125mg TDS 5 days
Last updated:
For detailed information click on the visual summary. complications:
Oct 2017 co-amoxiclav
Lower respiratory tract infections
Note: Low doses of penicillins are more likely to select for resistance.1D Do not use fluoroquinolones (ciprofloxacin, ofloxacin) first line because they may have long-term side
effects and there is poor pneumococcal activity.2B--,3D- Reserve all fluoroquinolones (including levofloxacin) for proven resistant organisms.1D
First choice: 500mg TDS (see
Acute BNF for severe -
exacerbation of amoxicillin OR infection)
COPD Many exacerbations are not caused by bacterial
infections so will not respond to antibiotics. 200mg on day 1, then
5 days
Consider an antibiotic, but only after taking into doxycycline OR 100mg OD (see BNF -
account severity of symptoms (particularly sputum for severe infection)
colour changes and increases in volume or 500mg BD (see BNF
thickness), need for hospitalisation, previous clarithromycin -
for severe infection)
exacerbations, hospitalisations and risk of
Second choice: use alternative first choice
complications, previous sputum culture and
susceptibility results, and risk of resistance with Alternative choice (if
repeated courses. person at higher risk of
500/125mg TDS -
Some people at risk of exacerbations may have treatment failure):
antibiotics to keep at home as part of their co-amoxiclav OR
5 days
exacerbation action plan. levofloxacin (consider
500mg OD -
For detailed information click on the visual summary. safety issues) OR
See also the NICE guideline on COPD in over 16s. co-trimoxazole (consider
Last updated: 960mg BD -
safety issues)
Dec 2018
IV antibiotics (click on visual summary)

Summary of antimicrobial prescribing guidance – managing common infections (February 2019) 3

 Doses Visual
Infection Key points Medicine Length
Adult Child summary
Acute cough Some people may wish to try honey (in over 1s), Adults first choice: 200mg on day 1, then
the herbal medicine pelargonium (in over 12s), 100mg OD -
cough medicines containing the expectorant doxycycline
guaifenesin (in over 12s) or cough medicines Adults alternative first
containing cough suppressants, except codeine, choices:
(in over 12s). These self-care treatments have 500mg TDS -
limited evidence for the relief of cough symptoms. amoxicillin OR
Acute cough with upper respiratory tract clarithromycin OR 250mg to 500mg BD -
infection: no antibiotic.
250mg to 500mg
Acute bronchitis: no routine antibiotic. erythromycin (preferred if QDS or
pregnant) -
Acute cough and higher risk of complications 500mg to 1000mg
(at face-to-face examination): immediate or back- BD
up antibiotic.
Children first choice: -
Acute cough and systemically very unwell (at
face to face examination): immediate antibiotic. amoxicillin

Higher risk of complications includes people with Children alternative first -

pre-existing comorbidity; young children born choices: 5 days
prematurely; people over 65 with 2 or more of, or clarithromycin OR
over 80 with 1 or more of: hospitalisation in
previous year, type 1 or 2 diabetes, history of erythromycin OR -
congestive heart failure, current use of oral
corticosteroids. doxycycline (not in under -
12s)
Do not offer a mucolytic, an oral or inhaled
bronchodilator, or an oral or inhaled corticosteroid
unless otherwise indicated.
For detailed information click on the visual
summary. See also the NICE guideline on
pneumonia for prescribing antibiotics in adults with
acute bronchitis who have had a C-reactive protein
Last updated: (CRP) test (CRP<20mg/l: no routine antibiotic,
Feb 2019
CRP 20 to 100mg/l: back-up antibiotic,
CRP>100mg/l: immediate antibiotic).

Summary of antimicrobial prescribing guidance – managing common infections (February 2019) 4

 Doses Visual
Infection Key points Medicine Length
Adult Child summary
Use CRB65 score to guide mortality risk, place of CRB65=0:
5 days
Community- care, and antibiotics.1D Each CRB65 parameter amoxicillin1D,4D OR 500mg TDS5A+
(review at
acquired scores one: Confusion (AMT<8 or new
clarithromycin2A+,4D,5A+ OR 500mg BD5A+ 3 days);1D
pneumonia disorientation in person, place or time); Respiratory
7–10 days if poor
rate >30/minute; BP systolic <90, or diastolic <60; 200mg stat then
doxycycline2A+,4D - response1D Not available.
age >65. 100mg OD6A-
Score 0: low risk, consider home-based care; CRB65 = 1–2 and at Access
supporting
Public Health 1–2: intermediate risk, consider hospital home: Clinically assess
evidence and
England assessment; need for dual therapy for rationales on the
3–4: urgent hospital admission.1D atypicals: PHE website
Give safety net advice1D and likely duration of amoxicillin1D, 4D AND 500mg TDS5A+ 7–10 days1D
different symptoms, such as cough 6 weeks.1D clarithromycin2A+,4D,5A+ OR 500mg BD5A+
Last updated: Clinically assess need for dual therapy for
Nov 2017 atypicals. Mycoplasma infection is rare in over 200mg stat then
doxycycline alone4D -
65s.2A+,3C 100mg OD6A-
Urinary tract infections
Non-pregnant women first
choice: nitrofurantoin (if 100mg m/r BD - 3 days
eGFR ≥45 ml/minute) OR
Lower urinary
tract infection Advise paracetamol or ibuprofen for pain. trimethoprim (if low risk of
200mg BD - 3 days
resistance)
Non-pregnant women: back up antibiotic (to use
if no improvement in 48 hours or symptoms Non-pregnant women
worsen at any time) or immediate antibiotic. second choice:
100mg m/r BD - 3 days
nitrofurantoin (if eGFR
Pregnant women, men, children or young ≥45 ml/minute OR
people: immediate antibiotic.
pivmecillinam (a penicillin) 400mg initial dose,
When considering antibiotics, take account of - 3 days
OR then 200mg TDS
severity of symptoms, risk of complications,
previous urine culture and susceptibility results, fosfomycin 3g single dose sachet - single dose
previous antibiotic use which may have led to Pregnant women first
resistant bacteria and local antimicrobial choice: nitrofurantoin (avoid
100mg m/r BD - 7 days
resistance data. at term) – if eGFR
For detailed information click on the visual summary. ≥45 ml/minute
See also the NICE guideline on urinary tract infection Pregnant women second
Last updated: in under 16s: diagnosis and management. choice: amoxicillin (only if
Oct 2018 500mg TDS - 7 days
culture results available and
susceptible) OR
cefalexin 500mg BD - 7 days

Summary of antimicrobial prescribing guidance – managing common infections (February 2019) 5

 Doses Visual
Infection Key points Medicine Length
Adult Child summary
Treatment of asymptomatic bacteriuria in pregnant women: choose from
nitrofurantoin (avoid at term), amoxicillin or cefalexin based on recent culture and
susceptibility results

Men first choice: 7 days

200mg BD -
trimethoprim OR
nitrofurantoin (if eGFR
≥45 ml/minute) 100mg m/r BD - 7 days

Men second choice: consider alternative diagnoses basing antibiotic choice on

recent culture and susceptibility results

Children and young

people (3 months and
over) first choice: -
trimethoprim (if low risk of
resistance) OR
nitrofurantoin (if eGFR
≥45 ml/minute) -

Children and young

people (3 months and -
over) second choice:
-
nitrofurantoin (if eGFR
≥45 ml/minute and not used
as first choice) OR
amoxicillin (only if culture
results available and -
susceptible) OR
cephalexin -

Summary of antimicrobial prescribing guidance – managing common infections (February 2019) 6

 Doses Visual
Infection Key points Medicine Length
Adult Child summary
Acute Advise paracetamol (+/- low-dose weak opioid) Non-pregnant women and 500mg BD or TDS
pyelonephritis for pain for people over 12. men first choice: (up to 1g to 1.5g TDS
- 7–10 days
(upper urinary Offer an antibiotic. or QDS for severe
tract) cefalexin OR infections)
When prescribing antibiotics, take account of
severity of symptoms, risk of complications, co-amoxiclav (only if culture
previous urine culture and susceptibility results, results available and 500/125mg TDS - 7–10 days
previous antibiotic use which may have led to susceptible) OR
resistant bacteria and local antimicrobial trimethoprim (only if culture
resistance data. results available and 200mg BD - 14 days
For detailed information click on the visual summary. susceptible) OR
See also the NICE guideline on urinary tract infection ciprofloxacin (consider
in under 16s: diagnosis and management.
safety issues) 500mg BD - 7 days

IV antibiotics (click on
- - -
visual summary)
Pregnant women first 500mg BD or TDS
choice: cefalexin (up to 1g to 1.5g TDS
- 7–10 days
or QDS for severe
infections)
Pregnant women second
choice or IV antibiotics
(click on visual summary) - - -
Last updated:
Oct 2018
Children and young
people (3 months and
- -
over) first choice: cefalexin
OR
co-amoxiclav (only if culture
results available and - - -
susceptible)
IV antibiotics (click on - - -
visual summary)

Summary of antimicrobial prescribing guidance – managing common infections (February 2019) 7

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

Summary of antimicrobial prescribing guidance – managing common infections (February 2019) 8

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

Summary of antimicrobial prescribing guidance – managing common infections (February 2019) 9

 Doses Visual
Infection Key points Medicine Length
Adult Child summary
Children and young
people (3 months and
over) first choice: -
trimethoprim (if low risk of
resistance) OR
amoxicillin (only if culture
results available and -
susceptible) OR

cefalexin OR -

co-amoxiclav (only if culture

results available and -
susceptible)
IV antibiotics (click on
- - -
visual summary)
First choice (guided
Acute 14 days then
susceptibilities when 500mg BD -
prostatitis review
Advise paracetamol (+/- low-dose weak opioid) available): ciprofloxacin OR
for pain, or ibuprofen if preferred and suitable. 14 days then
ofloxacin OR 200mg BD -
Offer antibiotic. review
Review antibiotic treatment after 14 days and trimethoprim (if unable to 14 days, then
200mg BD -
either stop antibiotics or continue for a further take quinolone) review
14 days if needed (based on assessment of Second choice (after
14 days, then
history, symptoms, clinical examination, urine discussion with specialist): 500mg OD -
review
and blood tests). levofloxacin OR
For detailed information click on the visual 14 days, then
co-trimoxazole 960mg BD -
summary. review
Last updated:
Oct 2018 IV antibiotics (click on
- - -
visual summary)

Summary of antimicrobial prescribing guidance – managing common infections (February 2019) 10

 Doses Visual
Infection Key points Medicine Length
Adult Child summary
Meningitis
Transfer all patients to hospital
Suspected
immediately.1D Not available.
meningococcal Stat dose;1D
disease If time before hospital admission,2D,3A+ if Child <1 year: 300mg5D Access the
suspected meningococcal septicaemia or non- give IM, if vein supporting
Public Health IV or IM benzylpenicillin1D,2D Child 1–9 years: 600mg5D evidence and
blanching rash,2D,4D give IV benzylpenicillin1D,2D,4D cannot be
England as soon as possible.2D Do not give IV antibiotics Adult/child 10+ years: 1.2g5D accessed 1D rationales on the
Last updated: PHE website
if there is a definite history of anaphylaxis;1D rash
Feb 2019
is not a contraindication.1D

Prevention of
secondary case
of meningitis Only prescribe following advice from your local health protection specialist/consultant:  [INSERT PHONE NUMBER]
Public Health Out of hours: contact on-call doctor:  [INSERT PHONE NUMBER]
England Access the supporting evidence and rationales on the PHE website.
Last updated:
Nov 2017
Gastrointestinal tract infections
Oral Topical azoles are more effective than topical 2.5ml of 24mg/ml 7 days; continue
candidiasis nystatin.1A+ Miconazole oral gel1A+,4D,5A- QDS (hold in mouth for 7 days after
Not available.
Oral candidiasis is rare in immunocompetent after food) 4D resolved4D,6D
Access
Public Health adults;2D consider undiagnosed risk factors, 1ml; 100,000units/mL 7 days; continue supporting
If not tolerated: nystatin
England including HIV.2D QDS (half in each for 2 days after evidence and
suspension2D,6D,7A- rationales on the
Use 50mg fluconazole if extensive/severe side) 2D,4D,7A- resolved4D
PHE website
Last updated: candidiasis;3D,4D if HIV or immunocompromised, 50mg/100mg
fluconazole capsules6D,7A- 7 to 14 days6D,7A-,8A-
Oct 2018 use 100mg fluconazole.3D,4D OD3D,6D,8A-
Infectious Refer previously healthy children with acute painful or bloody diarrhoea, to exclude E. coli O157 infection.1D
diarrhoea Antibiotic therapy is not usually indicated unless patient is systemically unwell.2D If systemically unwell and campylobacter suspected (such as
undercooked meat and abdominal pain),3D consider clarithromycin 250–500mg BD for 5–7 days, if treated early (within 3 days).3D,4A+
Public Health If giardia is confirmed or suspected – tinidazole 2g single dose is the treatment of choice.5A+
England
Access the supporting evidence and rationales on the PHE website.
Last updated:
Oct 2018

Summary of antimicrobial prescribing guidance – managing common infections (February 2019) 11

 Doses Visual
Infection Key points Medicine Length
Adult Child summary
Helicobacter Always test for H.pylori before giving antibiotics. Always use PPI2D,3D,5A+,12A+
pylori Treat all positives, if known DU, GU,1A+ or First line and first relapse
low-grade MALToma.2D,3D NNT in non-ulcer -
and no penicillin allergy
dyspepsia: 14.4A+ PPI PLUS 2 antibiotics
Do not offer eradication for GORD.3D
amoxicillin2D,6B+ PLUS 1000mg BD14A+
Do not use clarithromycin, metronidazole or
quinolone if used in the past year for any clarithromycin2D,6B+ OR 500mg BD8A-
infection.5A+,6B+,7A+
Penicillin allergy: use PPI PLUS clarithromycin metronidazole2D,6B+ 400mg BD2D
Public Health PLUS metronidazole.2D If previous
clarithromycin, use PPI PLUS bismuth salt PLUS Penicillin allergy and
England
metronidazole PLUS tetracycline previous clarithromycin:
PPI WITH bismuth -
hydrochloride.2D,8A-,9D 7 days2D
subsalicylate PLUS 2 -
Relapse and no penicillin allergy use PPI antibiotics MALToma
PLUS amoxicillin PLUS clarithromycin or bismuth subsalicylate13A+ 14 days7A+,16A+
See PHE quick metronidazole (whichever was not used first line) 525mg QDS15D Not available.
reference guide 2D
PLUS Access
for diagnostic metronidazole2D PLUS 400mg BD2D supporting
Relapse and previous metronidazole and evidence and
advice: PHE H.
clarithromycin: use PPI PLUS amoxicillin PLUS tetracycline2D 500mg QDS15D rationales on the
pylori
either tetracycline OR levofloxacin (if tetracycline Relapse and previous PHE website
not tolerated).2D,7A+ metronidazole and
Relapse and penicillin allergy (no exposure to clarithromycin: - -
quinolone): use PPI PLUS metronidazole PLUS PPI PLUS 2 antibiotics
levofloxacin.2D
Relapse and penicillin allergy (with exposure amoxicillin2D,7A+ PLUS 1000mg BD14A+
to quinolone): use PPI PLUS bismuth salt PLUS tetracycline2D,7A+ OR 500mg QDS15D
metronidazole PLUS tetracycline.2D
Last updated: levofloxacin2D,7A+ 250mg BD7A+
Feb 2019 Retest for H. pylori: post DU/GU, or relapse Third line on advice:
after second-line therapy,1A+ using UBT or - -
PPI WITH
SAT,10A+,11A+ consider referral for endoscopy and
culture.2D bismuth subsalicylate PLUS 525mg QDS15D -
10 days
2 antibiotics as above not
- -
previously used OR
rifabutin14A+ OR 150mg BD -
furazolidone17A+ 200mg BD -

Summary of antimicrobial prescribing guidance – managing common infections (February 2019) 12

 Doses Visual
Infection Key points Medicine Length
Adult Child summary
Clostridium First episode:
Review need for antibiotics,1D,2D PPIs,3B- and 400mg TDS1D,2D 10–14 days1D,4B-
difficile metronidazole2D,4B-
antiperistaltic agents and discontinue use where
possible.2D Mild cases (<4 episodes of stool/day) Severe, type 027 or
recurrent: 10–14 days,1D,2D
may respond without metronidazole;2D 125mg QDS1D,2D,5A- Not available.
then taper2D Access
70% respond to metronidazole in 5 days; 92% oral vancomycin1D,2D,5A-
supporting
Public Health respond to metronidazole in 14 days.4B- evidence and
England If severe (T>38.5, or WCC>15, rising rationales on the
creatinine, or signs/symptoms of severe Recurrent or second line: PHE website
colitis):2D treat with oral vancomycin,1D,2D,5A- 200mg BD5A- - 10 days5A-
fidaxomicin2D,5A-
review progress closely,1D,2D and consider
Last updated: hospital referral.2D
Oct 2018
Traveller’s Standby:
diarrhoea 500mg OD1D,3A+ - 1–3 days1D,2D,3A+ Not available.
Prophylaxis rarely, if ever,indicated.1D Consider azithromycin
Access
standby antimicrobial only for patients at high Prophylaxis/treatment: 2 tablets QDS1D,2D - 2 days1D,2D,4A- supporting
Public Health risk of severe illness,2D or visiting high-risk bismuth subsalicylate evidence and
England areas.1D,2D rationales on the
Last updated: PHE website
Oct 2018
Treat all household contacts at the same Child >6 months: 1 dose;3B- repeat in
Threadworm
time.1D 100mg stat3B- 2 weeks if
mebendazole1D,3B- Not available.
Advise hygiene measures for 2 weeks1D (hand persistent3B- Access
Public Health hygiene;2D pants at night; morning shower, Child <6 months or supporting
England including perianal area).1D,2D Wash sleepwear, pregnant (at least in first evidence and
bed linen, and dust and vacuum.1D trimester): - - - rationales on the
Last updated: PHE website
Child <6 months, add perianal wet wiping or only hygiene measure for
Nov 2017
washes 3 hourly.1D 6 weeks1D
Genital tract infections
STI screening
People with risk factors should be screened for chlamydia, gonorrhoea, HIV and syphilis. 1D Refer individual and partners to GUM.1D
Public Health Risk factors: <25 years; no condom use; recent/frequent change of partner; symptomatic or infected partner; area of high HIV.2B-
England Access the supporting evidence and rationales on the PHE website.
Last updated:
Nov 2017

Summary of antimicrobial prescribing guidance – managing common infections (February 2019) 13

 Doses Visual
Infection Key points Medicine Length
Adult Child summary
Chlamydia Opportunistically screen all sexually active
trachomatis/ patients aged 15 to 24 years for chlamydia First line:
urethritis annually and on change of sexual partner.1B- doxycycline4A+,11A-,12A+ 100mg BD4A+,11A-,12A+ 7 days4A+,11A-,12A+
If positive, treat index case, refer to GUM and
Public Health initiate partner notification, testing and
England treatment.2D,3A+
As single dose azithromycin has led to increased
Last updated:
resistance in GU infections, doxycycline should
Feb 2019 be used first line for chlamydia and urethritis.4A+
Advise patient to abstain from sexual intercourse
for 7 days after treatment.3A+,4A+ Not available.
Test positives for reinfection at 3 months Access
following treatment.1B-,5B- supporting
- evidence and
Second line, pregnant, breastfeeding, allergy, Second line/ rationales on the
or intolerance: azithromycin is most pregnant/breastfeeding/ PHE website
effective.6A+,7D,8A+,9A+,10D As lower cure rate in allergy/intolerance:
azithromycin4A+,11A-,12A+ 1000mg4A+,11A-,12A+ Stat4A+,11A-,12A+
pregnancy, test for cure at least 3 weeks after
end of treatment.3A+ then
Consider referring all patients with symptomatic 500mg OD4A+,11A-,12A+ 2 days4A+,11A-,12A+
urethritis to GUM as testing should include (total 3 days)
Mycoplasma genitalium and Gonorrhoea.11A-
If M.genitalium is proven, use doxycycline
followed by azithromycin using the same dosing
regimen.11A-,12A+

Epididymitis Doxycycline1A+,2D OR 100mg BD1A+,2D 10 to 14 days1A+,2D Not available.

Access
Usually due to Gram-negative enteric bacteria in ofloxacin1A+,2D OR 200mg BD1A+,2D - 14 days1A+,2D supporting
Public Health men over 35 years with low risk of STI.1A+,2D ciprofloxacin1A+,2D 500mg BD1A+,2D,3A+ 10 days1A+,2D,3A+ evidence and
England If under 35 years or STI risk, refer to GUM.1A+,2D rationales on the
Last updated: PHE website
Nov 2017

Summary of antimicrobial prescribing guidance – managing common infections (February 2019) 14

 Doses Visual
Infection Key points Medicine Length
Adult Child summary
Clotrimazole1A+,5D OR 500mg pessary1A+ Stat1A+
Vaginal All topical and oral azoles give over 80% fenticonazole1A+ OR 600mg pessary1A+ Stat1A+
candidiasis cure.1A+,2A+ -
clotrimazole1A+ OR 100mg pessary1A+ 6 nights1A+ Not available.
Pregnant: avoid oral azoles, the 7 day courses Access
oral fluconazole1A+,3D 150mg1A+,3D Stat1A+
Public Health are more effective than shorter ones.1A+,3D,4A+ supporting
England Recurrent (>4 episodes per year):1A+ 150mg 150mg every evidence and
oral fluconazole every 72 hours for 3 doses If recurrent: 72 hours 3 doses rationales on the
PHE website
induction,1A+ followed by 1 dose once a week for fluconazole THEN -
Last updated:
Oct 2018 6 months maintenance.1A+ (induction/maintenance)1A+ 150mg once a 6 months1A+
week1A+,3D
Bacterial 400mg BD1A+,3A+ 7 days1A+
vaginosis Oral metronidazole is as effective as topical Oral metronidazole1A+,3A+
OR OR Not available.
treatment,1A+ and is cheaper.2D OR
2000mg1A+,2D Stat2D Access
Public Health 7 days results in fewer relapses than 2g stat at supporting
metronidazole 0.75% 5g applicator at - evidence and
England 4 weeks.1A+,2D 5 nights1A+,2D,3A+
vaginal gel1A+,2D,3A+ OR night1A+,2D,3A+ rationales on the
Pregnant/breastfeeding: avoid 2g dose.3A+,4D
5g applicator at PHE website
Last updated: Treating partners does not reduce relapse.5A+ clindamycin 2% cream 1A+,2D 7 nights1A+,2D,3A+
Nov 2017 night1A+,2D
Genital herpes 400mg TDS1A+,3A+ 5 days1A+
Advise: saline bathing,1A+ analgesia,1A+ or topical
Oral aciclovir1A+,2D,3A+,4A+ OR 800mg TDS (if
lidocaine for pain,1A+ and discuss transmission.1A+ 2 days1A+ Not available.
Public Health recurrent)1A+ Access
First episode: treat within 5 days if new lesions
England valaciclovir1A+,3A+,4A+ OR 500mg BD1A+ 5 days1A+ supporting
or systemic symptoms,1A+,2D and refer to GUM.2D - evidence and
Recurrent: self-care if mild,2D or immediate short 250mg TD1A+ 5 days1A+ rationales on the
course antiviral treatment,1A+,2D or suppressive famciclovir1A+,4A+ 1000mg BD (if PHE website
Last updated: therapy if more than 6 episodes per year.1A+,2D 1 day1A+
Nov 2017
recurrent)1A+
Antibiotic resistance is now very high.1D,2D
Gonorrhoea Use IM ceftriaxone if susceptibility not known Ceftriaxone2D OR 1000mg IM2D Stat2D Not available.
prior to treatment2D. Access
Public Health supporting
England Use Ciprofloxacin only If susceptibility is known - evidence and
Last updated: prior to treatment and the isolate is sensitive to ciprofloxacin2D rationales on the
500mg2D Stat2D
Feb 2019 ciprofloxacin at all sites of infection1D,2D (only if known to be PHE website
Refer to GUM.3B- Test of cure is essential.2D sensitive)

Summary of antimicrobial prescribing guidance – managing common infections (February 2019) 15

 Doses Visual
Infection Key points Medicine Length
Adult Child summary
Trichomoniasis 400mg BD1A+,6A+ 5–7 day1A+
Oral treatment needed as extravaginal infection Metronidazole1A+,2A+,3D,6A+ 2g (more adverse
Stat1A+,6A+ Not available.
common.1D effects)6A+
Public Health Access
Treat partners,1D and refer to GUM for other Pregnancy to treat 100mg pessary at 6 nights5D
England supporting
STIs.1D symptoms: night5D - evidence and
Pregnant/breastfeeding: avoid 2g single dose clotrimazole2A+,4A-,5D rationales on the
metronidazole;2A+,3D clotrimazole for symptom PHE website
Last updated: relief (not cure) if metronidazole declined.2A+,4A-,5D
Nov 2017
Pelvic Refer women and sexual contacts to GUM.1A+ First line therapy:
inflammatory Ceftriaxone1A+,3C,4C PLUS 1000mg IM1A+,3C Stat1A+,3C
Raised CRP supports diagnosis, absent pus
disease
cells in HVS smear good negative predictive metronidazole1A+,5A+ PLUS 400mg BD1A+ 14 days1A+
value.1A+ doxycycline1A+,5A+ 100mg BD1A+ 14 days1A+ Not available.
Exclude: ectopic pregnancy, appendicitis, Second line therapy: Access
endometriosis, UTI, irritable bowel, complicated 400mg BD1A+ 14 days1A+ supporting
metronidazole1A+,5A+ PLUS - evidence and
Public Health ovarian cyst, functional pain.
ofloxacin1A+,2A-,5A+ rationales on the
England Moxifloxacin has greater activity against likely 400mg BD1A+,2A- 14 days1A+ PHE website
pathogens, but always test for gonorrhoea, OR
chlamydia, and M. genitalium .1A+ moxifloxacin alone1A+
Last updated:
If M. genitalium tests positive use (first line for M. genitalium 400mg OD1A+ 14 days1A+
Feb 2019 moxifloxacin.1A+ associated PID)
Skin and soft tissue infections
Note: Refer to RCGP Skin Infections online training.1D For MRSA, discuss therapy with microbiologist.1D

Impetigo Topical fusidic acid2D,3A+ Thinly TDS4D 5 days1D,2D

Reserve topical antibiotics for very localised If MRSA: Not available.
lesions to reduce risk of bacteria becoming 2% ointment TDS3A+ 5 days1D,2D,3A+ Access
Public Health topical mupirocin 3A+ supporting
England resistant.1D,2B+ Only use mupirocin if caused by
More severe: 250 to 500mg evidence and
MRSA.1D,3A+ 7 days3A+ rationales on the
Extensive, severe, or bullous: oral antibiotics.4D oral flucloxacillin1D,3A+ OR QDS3A+
Last updated: PHE website
Nov 2017 oral clarithromycin1D,4D 250 to 500mg BD1D,4D 7 days4D

Summary of antimicrobial prescribing guidance – managing common infections (February 2019) 16

 Doses Visual
Infection Key points Medicine Length
Adult Child summary
Cold sores
Public Health Most resolve after 5 days without treatment.1A-,2A- Topical antivirals applied prodromally can reduce duration by 12 to 18 hours.1A-,2A-,3A-
England If frequent, severe, and predictable triggers: consider oral prophylaxis:4D,5A+ aciclovir 400mg, twice daily, for 5 to 7 days.5A+,6A+
Last updated: Access supporting evidence and rationales on the PHE website
Nov 2017
Panton-Valentine leukocidin (PVL) is a toxin produced by 20.8 to 46% of S. aureus from boils/abscesses.1B+,2B+,3B- PVL strains are rare in healthy people,
PVL-SA but severe.2B+
Public Health Suppression therapy should only be started after primary infection has resolved, as ineffective if lesions are still leaking. 4D
England
Risk factors for PVL: recurrent skin infections;2B+ invasive infections;2B+ MSM;3B- if there is more than one case in a home or close community2B+,3B-
Last updated:
Nov 2017
(school children;3B- military personnel;3B- nursing home residents;3B- household contacts).3B-
Access the supporting evidence and rationales on the PHE website.
Eczema
Public Health No visible signs of infection: antibiotic use (alone or with steroids)1A+ encourages resistance and does not improve healing.1A+
England With visible signs of infection: use oral flucloxacillin2D or clarithromycin,2D or topical treatment (as in impetigo).2D
Last updated: Access the supporting evidence and rationales on the PHE website.
Nov 2017
Leg ulcer Flucloxacillin5D OR 500mg QDS5D 7 days
If slow response Not available.
Ulcers are always colonised.1C,2A+
Public Health continue for Access
Antibiotics do not improve healing unless active clarithromycin5D 500mg BD5D
England another 7 days5D supporting
infection2A+ (only consider if purulent evidence and
exudate/odour; increased pain; cellulitis; rationales on the
Last updated: pyrexia).3D Non-healing ulcers: antimicrobial-reactive oxygen gel may reduce bacterial PHE website
Feb 2019 load.6D,7B-

Mild (open and closed comedones)1D or Second line: topical

Thinly OD3A+ 6–8 weeks1D
moderate (inflammatory lesions):1D retinoid1D,2D,3A+ OR
Acne First line: self-care1D (wash with mild soap; do
benzoyl peroxide1A-,2D,3A+,4A- 5% cream OD-BD3A+ 6–8 weeks1D
not scrub; avoid make-up).1D Not available.
Second line: topical retinoid or benzoyl Third-line: topical 1% cream, thinly Access
Public Health 12 weeks1A-,2D
peroxide.2D clindamycin3A+ BD3A+ supporting
England Third-line: add topical antibiotic,1D,3A+ or consider If treatment failure/severe: evidence and
500mg BD3A+ 6–12 weeks3A+ rationales on the
addition of oral antibiotic.1D oral tetracycline1A-,3A+ OR
PHE website
Severe (nodules and cysts):1D add oral oral doxycycline3A+,4A- 100mg OD3A+ 6–12 weeks3A+
Last updated:
Nov 2017 antibiotic (for 3 months max)1D,3A+ and refer.1D,2D

Summary of antimicrobial prescribing guidance – managing common infections (February 2019) 17

 Doses Visual
Infection Key points Medicine Length
Adult Child summary
Class I: patient afebrile and healthy other than Flucloxacillin1D,2D,3A+ 500mg QDS1D,2D
Cellulitis and cellulitis, use oral flucloxacillin alone.1D,2D,3A+
erysipelas If river or sea water exposure: seek advice.1D Penicillin allergy:
500mg BD1D,2D
Class II: patient febrile and ill, or comorbidity, clarithromycin1D,2D,3A+,6A+ Not available.
admit for IV treatment,1D or use outpatient Penicillin allergy and 7 days;1D if slow Access
Public Health 200mg stat then
parenteral antimicrobial therapy.1D taking statins: response, continue supporting
England 100mg OD2D evidence and
Class III: if toxic appearance, admit.1D doxycycline2D for a further
Adding clindamycin does not improve 7 days1D rationales on the
PHE website
outcomes4B+
Facial (non-dental):
Erysipelas: often facial and unilateral.5B+ 500/125mg TDS1D
Last updated: co-amoxiclav7B-
Oct 2018 Use flucloxacillin for non-facial erysipelas.1D,2D,3A+

Prophylaxis/treatment all:
Bites Human: thorough irrigation is important.1A+,2D
co-amoxiclav2D,3D 375–625mg TDS3D 7 days3D
Antibiotic prophylaxis is advised.1A+,2D,3D Assess
risk of tetanus, rabies,1A+ HIV, and hepatitis B
and C.3D Human penicillin allergy:
Cat: always give prophylaxis.1A+,3D metronidazole3D,4A+ AND 400mg TDS2D 7 days3D
Not available.
Public Health clarithromycin3D,4A+ 250mg–500mg BD2D Access
England Dog: give prophylaxis if: puncture wound;1A+,3D supporting
bite to hand, foot, face, joint, tendon, or evidence and
Animal penicillin allergy:
ligament;1A+ immunocompromised; cirrhotic; rationales on the
metronidazole3D,4A+ AND 400mg TDS2D 7 days3D
asplenic; or presence of prosthetic PHE website
valve/joint.2D,4A+ doxycycline3D 100mg BD2D
Last updated: Penicillin allergy: Review all at 24 and
If pregnant, and rash after
Oct 2018 48 hours,3D as not all pathogens are covered.2D,3
penicillin: ceftriaxone5C 1–2g OD IV or IM5C - NA

First choice permethrin: Treat whole body from Permethrin1D,2D,3A+ 5% cream1D,2D

ear/chin downwards,1D,2D and under nails.1D,2D
Scabies If using permethrin and patient is under
2 years, elderly or immunosuppressed, or if Not available.
Public Health treating with malathion: also treat face and Access
England scalp.1D,2D 2 applications, supporting
Home/sexual contacts: treat within 24 hours.1D Permethrin allergy: 0.5% aqueous 1 week apart1D evidence and
malathion1D liquid1D rationales on the
Last updated: PHE website
Oct 2018

Summary of antimicrobial prescribing guidance – managing common infections (February 2019) 18

 Doses Visual
Infection Key points Medicine Length
Adult Child summary
Mastitis S. aureus is the most common infecting Flucloxacillin2D 500mg QDS2D
Not available.
pathogen.1D Suspect if woman has: a painful Penicillin allergy:
250–500mg QDS2D Access
Public Health breast;2D fever and/or general malaise;2D a erythromycin2D OR supporting
England tender, red breast.2D - 10–14 days2D evidence and
Breastfeeding: oral antibiotics are appropriate, rationales on the
clarithromycin2D 500mg BD2D
Last updated: where indicated.2D,3A+ Women should continue PHE website
Nov 2017 feeding,1D,2D including from the affected breast.2D
Most cases: use terbinafine as fungicidal, Topical terbinafine3A+,4D OR 1% OD to BD2A+ 1–4 weeks3A+
Dermatophyte treatment time shorter and more effective than
infection: skin with fungistatic imidazoles or topical imidazole2A+,3A+ 1% OD to BD2A+ 4–6 weeks2A+,3A+ Not available.
undecenoates.1D,2A+,If candida possible, use Access
imidazole.4D Alternative in athlete’s OD to BD2A+ supporting
Public Health
If intractable, or scalp: send skin scrapings,1D foot: evidence and
England
and if infection confirmed: use oral topical undecenoates2A+ rationales on the
(such as Mycota®)2A+ PHE website
Last updated: terbinafine1D,3A+,4D or itraconazole.2A+,3A+,5D
Feb 2019 Scalp: oral therapy,6D and discuss with
specialist.1D
Dermatophyte Take nail clippings;1D start therapy only if Fingers:
infection: nail infection is confirmed.1D Oral terbinafine is more First line: 6 weeks1D,6D
250mg OD1D,2A+,6D
effective than oral azole.1D,2A+,3A+,4D Liver terbinafine1D,2A+,3A+,4D,6D Toes: Not available.
reactions 0.1 to 1% with oral antifungals.3A+ If 12 weeks1D,6D Access
Public Health candida or non-dermatophyte infection is 1 week a month1D supporting
confirmed, use oral itraconazole.1D,3A+,4D Topical Second line: Fingers: evidence and
England 200mg BD1D,4D
nail lacquer is not as effective.1D,5A+,6D itraconazole1D,3A+,4D,6D 2 courses1D rationales on the
PHE website
To prevent recurrence: apply weekly 1% topical Toes: 3 courses1D
Last updated: antifungal cream to entire toe area.6D
Oct 2018 Stop treatment when continual, new, healthy, proximal nail growth.6D
Children: seek specialist advice.4D

Summary of antimicrobial prescribing guidance – managing common infections (February 2019) 19

 Doses Visual
Infection Key points Medicine Length
Adult Child summary
Pregnant/immunocompromised/ First line for chicken pox
Varicella neonate: seek urgent specialist advice.1D and shingles: 800mg 5 times
zoster/ Chickenpox: consider aciclovir2A+,3A+,4D if: onset aciclovir3A+,7A+,10A+,13B+,14A- daily16A-
chickenpox of rash <24 hours,3A+ and 1 of the following:
,15A+
Not available.
>14 years of age;4D severe pain;4D dense/oral Second line for shingles if Access
rash;4D,5B+ taking steroids;4D smoker.4D,5B+ poor compliance: 250–500mg TDS15A+ 7 days14A-,16A- supporting
OR - evidence and
Herpes zoster/ Give paracetamol for pain relief.6C not for children:
750mg BD15A+ rationales on the
shingles Shingles: treat if >50 years7A+,8D (PHN rare if famciclovir8D,14A-, 16A- OR PHE website
<50 years)9B+ and within 72 hours of rash,10A+ or valaciclovir8D,10A+,14A- 1g TDS14A-
if 1 of the following: active ophthalmic;11D
Ramsey Hunt;4D eczema;4D non-truncal
involvement;8D moderate or severe pain;8D
Public Health moderate or severe rash.5B+,8D
England Shingles treatment if not within 72 hours:
consider starting antiviral drug up to 1 week after
rash onset,12B+ if high risk of severe shingles12B+
Last updated: or continued vesicle formation;4D older
Oct 2018 age;7A+,8D,12B+ immunocompromised;4D or severe
pain.7D,11B+
Prophylaxis:1A+ not routinely recommended in
Tick bites
Europe.2D In pregnancy, consider amoxicillin.2D
(Lyme disease)
If immunocompromised, consider prophylactic
doxycycline.2D Risk increased if high prevalence
area and the longer tick is attached to the skin.3D Prophylaxis:1A+
200mg2D,4A,5D Stat2D,4A-,5D
Only give prophylaxis within 72 hours of tick doxycycline2D,4A-,5D Not available.
removal.1A+,2D,4A- Give safety net advice about Access
Public Health
erythema migrans2D and other possible supporting
England evidence and
symptoms2D that may occur within 1 month of tick
rationales on the
removal.2D PHE website
Treatment: Treat erythema migrans empirically; Treatment:
100mg BD2D,3D,5D
serology is often negative early in infection.3D doxycycline2D,3D,5D
For other suspected Lyme disease such as First alternative: 1,000mg TDS2D,3D,5D
Last updated: Oct neuroborreliosis (CN palsy, radiculopathy) seek 21 days2D,3D,5D
2018 amoxicillin2D,3D,5D
advice.3D

Summary of antimicrobial prescribing guidance – managing common infections (February 2019) 20

 Doses Visual
Infection Key points Medicine Length
Adult Child summary
Eye infections
First line: bath/clean eyelids with cotton wool Second line: 2 hourly for
Conjunctivitis dipped in sterile saline or boiled (cooled) water, 2 days,1D,2A+ then
chloramphenicol1D,2A+,4A-,5A+
to remove crusting.1D reduce frequency1D to
0.5% eye drop1D,2A+
Treat only if severe,2A+ as most cases are viral3D 3–4 times daily,1D or Not available.
OR just at night if using Access
Public Health or self-limiting.2A+ 48 hours after
1% ointment1D,5A+ eye ointment1D supporting
England Bacterial conjunctivitis: usually unilateral and resolution2A+,7D evidence and
also self-limiting.2A+,3D It is characterised by red rationales on the
eye with mucopurulent, not watery discharge.3D Third line: PHE website
65% and 74% resolve on placebo by days 5 and BD1D,7D
Last updated: fusidic acid 1% gel2A+,5A+,6A-
Oct 2018
7.4A-,5A+ Third line: fusidic acid as it has less
Gram-negative activity.6A-,7D
First line: lid hygiene1D,2A+ for symptom control,1D Second line:
Blepharitis
including: warm compresses;1D,2A+ lid massage topical 1% ointment BD2A+,3D 6-week trial3D Not available.
and scrubs;1D gentle washing;1D avoiding chloramphenicol1D,2A+,3A- Access
Public Health cosmetics.1D supporting
England Third line: 500mg BD3D 4 weeks (initial)3D
Second line: topical antibiotics if hygiene evidence and
measures are ineffective after 2 weeks.1D,3A+ oral oxytetracycline1D,3D OR 250mg BD3D 8 weeks (maint)3D rationales on the
Last updated: 100mg OD3D 4 weeks (initial)3D PHE website
Signs of meibomian gland dysfunction,3D or oral doxycycline1D,2A+,3D
Nov 2017 50mg OD3D 8 weeks (maint)3D
acne rosacea:3D consider oral antibiotics.1D
Suspected dental infections in primary care (outside dental settings)
Derived from the Scottish Dental Clinical Effectiveness Programme (SDCEP) 2013 Guidelines. This guidance is not designed to be a definitive guide to oral conditions, as
GPs should not be involved in dental treatment. Patients presenting to non-dental primary care services with dental problems should be directed to their regular dentist, or if
this is not possible, to the NHS 111 service (in England), who will be able to provided details of how to access emergency dental care.
Note: Antibiotics do not cure toothache.1D First-line treatment is with paracetamol1D and/or ibuprofen;1D codeine is not effective for toothache.1D
Mucosal Temporary pain and swelling relief can be Chlorhexidine
ulceration and attained with saline mouthwash (½ tsp salt in 0.12 to 0.2%1D, 2A-,3A+,4A+ (do
not use within 30 minutes of 1 minute BD with Always spit out Not available.
inflammation warm water)1D. Use antiseptic mouthwash if more 10 ml1D
toothpaste)1D after use.1D Access
(simple severe,1D and if pain limits oral hygiene to treat or
Use until lesions supporting
gingivitis) prevent secondary infection.1D,2A- The primary OR
resolve1D or evidence and
Public Health cause for mucosal ulceration or inflammation 2 to 3 minutes rationales on the
(aphthous ulcers;1D oral lichen planus;1D herpes less pain allows for
England BD/TDS with 15ml in oral hygiene1D PHE website
simplex infection;1D oral cancer)1D needs to be hydrogen peroxide 6%5A- 1D
Last updated: ½ glass warm
Nov 2017 evaluated and treated.1D water1D

Summary of antimicrobial prescribing guidance – managing common infections (February 2019) 21

 Doses Visual
Infection Key points Medicine Length
Adult Child summary
Acute Chlorhexidine 0.12 to 0.2%
1 minute BD with
necrotising Refer to dentist for scaling and hygiene (do not use within 30
10ml1D Not available.
ulcerative advice.1D,2D minutes of toothpaste)1D OR Until pain allows for Access
gingivitis Antiseptic mouthwash if pain limits oral 2 to 3 minutes oral hygiene6D supporting
Public Health hygiene.1D hydrogen peroxide 6%1D BD/TDS with 15ml in evidence and
England ½ glass warm water rationales on the
Commence metronidazole if systemic signs and
PHE website
Last updated: symptoms.1D,2D,3B-,4B+,5A-
Nov 2017 metronidazole1D,3B-,4B+,5A- 400mg TDS1D,2D 3 days1D,2D
Refer to dentist for irrigation and debridement.1D Metronidazole1D,2A+,3B+ OR 400mg TDS1D 3 days1D,2A+
Pericoronitis
If persistent swelling or systemic symptoms,1D
use metronidazole1D,2A+,3B+ or amoxicillin.1D,3B+ amoxicillin1D,3B+ 500mg TDS1D 3 days1D
Not available.
Use antiseptic mouthwash if pain and trismus Access
Public Health limit oral hygiene.1D chlorhexidine 0.2% (do not
1 minute BD with supporting
England use within 30 minutes of
10ml1D evidence and
toothpaste)1D OR Until less pain rationales on the
2 to 3 minutes allows for oral PHE website
BD/TDS with 15ml in hygiene1D
Last updated: hydrogen peroxide 6%1D
Nov 2017 ½ glass warm
water1D
Regular analgesia should be the first option1A+ until a dentist can be seen for urgent drainage,1A+,2B-,3A+ as repeated courses of antibiotics for abscesses are
Dental abscess
not appropriate.1A+,4A+ Repeated antibiotics alone, without drainage, are ineffective in preventing the spread of infection. 1A+,5C Antibiotics are only
recommended if there are signs of severe infection,3A+ systemic symptoms,1A+,2B-,4A+ or a high risk of complications.1A+ Patients with severe odontogenic
infections (cellulitis,1A+,3A+ plus signs of sepsis;3A+,4A+ difficulty in swallowing;6D impending airway obstruction)6D should be referred urgently for hospital
admission to protect airway,6D for surgical drainage3A+ and for IV antibiotics. 3A+ The empirical use of cephalosporins,6D co-amoxiclav,6D clarithromycin,6D
and clindamycin6D do not offer any advantage for most dental patients,6D and should only be used if there is no response to first-line drugs.6D
If pus is present, refer for drainage,1A+,2B- tooth 500mg to 1000mg
Public Health Amoxicillin6D,8B+,9C,10B+ OR
extraction,2B- or root canal.2B- TDS6D
England
Send pus for investigation.1A+ 500mg to 1000mg Not available.
phenoxymethylpenicillin11B- Access
If spreading infection1A+ (lymph node QDS6D Up to 5 days;
6D,10B+ review at supporting
involvement1A+,4A+ or systemic signs,1A+,2B-,4A+ that evidence and
metronidazole6D,8B+,9C 400mg TDS6D 3 days9C,10B+
is, fever1A+ or malaise)4A+ ADD rationales on the
metronidazole.6D,7B+ PHE website
Last updated: Penicillin allergy:
Use clarithromycin in true penicillin allergy6D and, 500mg BD6D
Oct 2018 clarithromycin6D
if severe, refer to hospital.3A+,6D

Summary of antimicrobial prescribing guidance – managing common infections (February 2019) 22

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

Summary of antimicrobial prescribing guidance – managing common infections (February 2019) 23