Children:

Refer to: Hospital: Paediatrics (Skin and Soft Tissue Infection - Cellulitis)

Adults:

Flucloxacillin dose

Penicillin Allergy or Known MRSA^#: Doxycycline dose (Pregnant: Clarithromycin dose)

Duration: 5 days; up to 10-14 days may be required if severe/extensive/slow to respond


Facial infection, not requiring admission

Co-Amoxiclav dose

Penicillin Allergy or Known MRSA^#: Doxycycline dose + Metronidazole dose (Pregnant: Clarithromycin dose + Metronidazole dose)

Duration: 7 days

Refer to: Primary Care (Eye - Orbital / peri-orbital cellulitis)

Reserve topical antibiotics for very localised lesions.

Topical Fusidic Acid 2% cream can be prescribed in community pharmacies via Pharmacy First for adults/children in minor/localised, uncomplicated cases. 

Minor/localised: topical Fusidic Acid 2% dose

Severe/extensive or bullous: Flucloxacillin dose

Penicillin Allergy or MRSA suspected^#: Doxycycline (Pregnant: Clarithromycin) dose

Duration: 5 days

Skin

Advise on self-care management strategies to reduce recurrence.

Topical clotrimazole 1% dose, miconazole 2% dose or terbinafine 1% dose cream

Marked inflammation: Add topical hydrocortisone 1% (BD, up to 7 days)

Duration: consult selected product literature

Refer to:

• NICE / CKS Fungal skin infection - body and groin
• NICE / CKS Fungal skin infection - foot

Nail

Confirm with nail clippings prior to treatment.

Offer oral antifungal if confirmed fungal nail infection and self-care measures alone and/or topical treatment are not successful or appropriate.

Terbinafine dose

Duration:

• Hands: 6-12 weeks
• Feet: 6 months

Refer to: NICE / CKS Fungal nail infection

Children:

Refer to: Hospital: Paediatrics (Skin and Soft Tissue Infection - Human / Animal bite)

Adults:

Assess type and severity (incl. causative animal), wound depth and site, and whether it is infected or not. Consider need for antibiotic prophylaxis, as per NICE guidance.

Assess tetanus and rabies risk.

For human bites assess HIV and hepatitis risk.

Send a wound swab for culture if discharge is present (purulent or non-purulent). To ensure appropriate laboratory testing, clinical details must state this is a human / animal bite (detail which animal).

Co-amoxiclav dose

Penicillin Allergy: Doxycycline dose + Metronidazole dose (Pregnant: discuss with Microbiology)

Duration:

• Prophylaxis: 3 days
• Treatment (i.e. infected): 5 days

Antibiotic therapy is to treat infection, NOT heal ulcers / wounds.

Do NOT use wound swabs to diagnose infection - wound infection is a clinical diagnosis (see IWII 2022 Wound Infection Continuum: Diagnosis of Wound Infection).

Do NOT routinely culture uninfected wounds.

Wound Swabs (how to swab) / bone culture samples should be obtained prior to initiation of antibiotic therapy. Clinical details should include "diabetes"  to ensure appropriate laboratory testing.

Determine severity of wound infection (mild/moderate/severe*), as per IWGDF/IDSA Infection guideline, to determine most appropriate antibiotic therapy.

Follow Acute Foot Deterioration in a Patient Living with Diabetes Pathway. Consider referral to Diabetes Foot Clinic.

Mild^*:

• No evidence of systemic infection AND
  • 2 or more features of inflammation: pus, erythema, pain, tenderness, warmth, induration
  •    OR
  • Cellulitis extending <2cm from wound margin.

Flucloxacillin dose

Penicillin Allergy or Known MRSA^# or Non-antibiotic naïve: Doxycycline dose

Duration: 7 days

Moderate^*:

• No evidence of systemic infection AND
• 2 or more features of inflammation: pus, erythema, pain, tenderness, warmth, induration INVOLVING
  • tissue deeper than skin and subcutaneous tissues (e.g., tendon, muscle, joint, and bone)
  •    OR
  • cellulitis extending >2cm from wound margin

Consider need for Secondary Care assessment (e.g. surgical input required). If no complicating factors, likely can be manged in Primary care with oral antibiotics.

Co-amoxiclav dose

Penicillin Allergy or Known MRSA^# or Non-antibiotic naïve: Doxycycline or Co-trimoxazole or Clindamycin dose

Duration: 7 days; may need up to 14 days if slow response. If osteomyelitis is diagnosed 4 - 6 weeks of therapy is usually indicated. 

Severe^*:

• Evidence of systemic infection AND foot infection

Requires hospital admission for IV antibiotics and assessment

Treat erythema migrans empirically.

Prophylactic antibiotic in the absence of signs/symptoms following a tick bite is NOT recommended.

Base need for serology testing on algorithm within the SLDTRL User Manual:

Click image for larger version / pdf.

All serology requests must include: symptoms, time between tick bite / possible exposure and onset of illness. Samples with inadequate clinical details (e.g. ?lyme, tick bite) will not be referred for testing.

For management guidance and antibiotic choice/duration, refer to NICE Lyme disease guidance.

Advise two applications one week apart.

Treat all household members and sexual contacts. 

Pregnant women can be treated.

Treat entire body below ear/chin including under nails.

Include face and scalp in under 2's and elderly patients.

Permethrin 5% cream dose (adults and children >2 months) 

Second line: Malathion 0.5% liquid dose (adults and children >6 months)

Refer to: NICE/CKS: Management of Scabies

Send a wound swab for culture if discharge is present (purulent or non-purulent). Include relevant clinical details. 

If there is no clinical improvement on empirical therapy, consider adjusting antibiotics according to swab results.

Do NOT use wound swabs to diagnose infection - wound infection is a clinical diagnosis (see IWII 2022 Wound Infection Continuum: Diagnosis of Wound Infection).

Flucloxacillin dose

Penicillin Allergy or Known MRSA^#: Doxycycline dose (Pregnant or Breast Feeding: Clarithromycin dose) Duration: 5 - 7 days

PLEASE REFER TO Obstetrics and Gynaecology Antimicrobial Formulary

Advise women to continue breastfeeding, including from affected breast if possible.

Encourage simple analgesia for pain/discomfort.

Send breast milk sample for culture in cases of treatment failure.

Identify and manage predisposing factors e.g. breastfeeding problems - refer health visitor or NHS breastfeeding support. 

Flucloxacillin dose

Penicillin Allergy or Known MRSA^#: Clarithromycin dose or Co-trimoxazole*dose


No improvement after 48 hours, and hospital admission is not required

Co-amoxiclav dose

Penicillin Allergy or Known MRSA^#: Clarithromycin dose (or Co-trimoxazole^*,dose) + Metronidazole dose

* Avoid during pregnancy and whilst breastfeeding: in the first 6 weeks after birth, where there is a possibility of G6PD deficiency, or if baby is jaundiced. Seek Microbiology advice.Duration: 7 - 14 days, depending on severity and response

Refer to: NICE Mastitis and Breast Abscess