Principles of treatment

1. These guidelines summary table are based on the best available evidence but use professional judgement and involve patients in management decisions.
2. These guidelines should not be used in isolation; it should be supported with patient information about safety netting, back-up antibiotics, self-care, infection severity and usual duration, clinical staff education, and audits. Materials are available on the RCGP TARGET website.
3. Prescribe an antibiotic only when there is likely to be clear clinical benefit, giving alternative, non-antibiotic self-care advice, where appropriate.
4. If person is systemically unwell with symptoms or signs of serious illness or is at high risk of complications: give immediate antibiotic. Always consider the possibility of sepsis and refer to hospital if severe systemic infection is suspected. 
5. Use a lower threshold for antibiotics in immunocompromised, or in those with multiple morbidities; consider culture/specimens and seek advice.
6. In severe infection, or immunocompromised, it is important to initiate antibiotics as soon as possible, particularly if sepsis is suspected. If patient is not at moderate to high risk for sepsis, give information about symptom monitoring, and how to access medical care if they are concerned.
7. Where an empirical therapy has failed, or special circumstances exist contact your local microbiologist for advice.

• Luton and Dunstable Hospital: (01582) 497318 / 497319
• Bedford Hospital: (01234) 795913
• Milton Keynes Hospital: 01908 995 782/779

8. Use simple, generic antibiotics if possible. Avoid broad spectrum antibiotics (for example co-amoxiclav, quinolones and cephalosporins) when narrow spectrum antibiotics remain effective, as they increase the risk of Clostridium difficile, MRSA and resistant UTIs.
9. Avoid widespread use of topical antibiotics, especially if those agents also available systemically (for example fusidic acid); in most cases, topical use should be limited.
10. Always check for hypersensitivity and if patient is genuinely allergic to penicillin use the recommended alternative(s) listed.
11. A dose and duration of treatment for adults is usually suggested, but may need modification for age, weight, renal function, or if immunocompromised. In severe or recurrent cases, consider a larger dose or longer course. Children’s doses are provided when appropriate but refer to the children’s BNF for full information.
12. Avoid use of quinolones unless benefits outweigh the risk as new 2018 evidence indicates that they may be rarely associated with long lasting disabling neuro­muscular and skeletal side effects.
13. Refer to the BNF for further dosing and interaction information (for example the macrolides).

Allergies

All patients should have an allergy history recorded including the date and nature of reaction where possible.

Penicillin allergy

Patients with a documented penicillin allergy should be reviewed to exclude a non-immunological adverse reaction, e.g. diarrhoea or vomiting. 

All beta-lactams including Cephalosporins and Carbapenems should be avoided if the allergy history suggests angioedema (blistering or swelling,) bronchospasm, or urticaria (itchy rash) within minutes to hours after penicillin administration (type 1 hypersensitivity reaction), or a severe delayed reaction, e.g. serum sickness like reaction (vasculitic rash) drug rash with eosinophilia and systemic symptoms (DRESS) Stevens-Johnson syndrome / toxic epidermal necrolysis or if the allergy history is unclear.

Cephalosporins may be used with caution in other types of allergic reactions. 

Co-trimoxazole – Co-trimoxazole contains trimethoprim and a sulphur-based product.  Check for allergies to sulphur before prescribing.

Drug safety information

The following are a non-exhaustive list of recent MHRA alerts:

Fluoroquinolone antibiotics: new restrictions and precautions for use due to very rare reports of disabling and potentially long-lasting or irreversible side effects - GOV.UK  March 2019

Among other recommendations, HCPs are advised to advise patients to stop treatment at the first signs of a serious adverse reactions, such as tendinitis or tendon rupture, muscle pain, muscle weakness, joint pain, joint swelling, peripheral neuropathy, and central nervous effects, and to contact their doctor immediately for further advice.

Systemic and inhaled fluoroquinolones: small increased risk of aortic aneurysm and dissection; advice for prescribing in high-risk patients - GOV.UK  Nov 2018

Use after a careful risk-benefit assessment in patients at risk of aortic aneurysm and dissection.

Systemic and inhaled fluoroquinolones: small risk of heart valve regurgitation; consider other therapeutic options first in patients at risk - GOV.UK Dec 2020

Erythromycin: caution required due to cardiac risks (QT interval prolongation); drug interaction with rivaroxaban - GOV.UK Dec 2020

Erythromycin should not be given to patients with a history of QT interval prolongation or ventricular cardiac arrhythmia, including torsade de pointes, or patients with electrolyte disturbances.

NICE. Summary of antimicrobial prescribing guidance – managing common infections. Aug 2021. Available via https://www.bnf.org/wp-content/uploads/2021/09/summary-antimicrobial-prescribing-guidance_aug-21_final.pdf

PHE. PHE guidance on use of antiviral agents for the treatment and prophylaxis of seasonal influenza. Sept 2019. Available via  https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/833572/PHE_guidance_antivirals_influenza_201920.pdf

BASHH 2015 UK national guideline for the management of infection with Chlamydia trachomomatis, updated Sept 2018. Available via https://www.bashh.org/guidelines 

NICE NG198 Acne vulgaris: management. June 2021. https://www.nice.org.uk/guidance/ng198

Scottish Dental Clinical Effectiveness Programme.  Management of Acute Dental Problems. Guidance for healthcare professionals. 2013.  https://www.sdcep.org.uk/published-guidance/management-of-acute-dental-problems-madp/