Summary of antimicrobial guidance
Skin Infection text summaries
Contents
Eczema (Bacterial Infection)
Manage underlying eczema and flares with treatments such as emollients and topical corticosteroids, whether antibiotics are given or not.
Symptoms and signs of secondary bacterial infection can include: weeping, pustules, crusts, no response to treatment, rapidly worsening eczema, fever and malaise.
Not all flares are caused by a bacterial infection, so will not respond to antibiotics.
Eczema is often colonised with bacteria but may not be clinically infected.
Do not routinely take a skin swab.
Not systemically unwell:
Do not routinely offer either a topical or oral antibiotic.
If an antibiotic is offered, when choosing between a topical or oral antibiotic, take account of patient preferences, extent and severity of symptoms or signs, possible adverse effects, and previous use of topical antibiotics because antimicrobial resistance can develop rapidly with extended or repeated use.
Systemically unwell:
Offer an oral antibiotic.
If there are symptoms or signs of cellulitis, see cellulitis and erysipelas.
If not systemically unwell, do not routinely offer either a topical or oral antibiotic
Topical antibiotic (if a topical is appropriate). For localised infections only:
First choice adult:
fusidic acid 2% TDS for 5 to 7 days
Oral antibiotic:
First choice adult:
flucloxacillin 500mg QDS for 5 to 7 days
Penicillin allergy or flucloxacillin unsuitable in adults:
clarithromycin 250mg BD (can be increased to 500mg BD for severe infections) for 5 to 7 days
OR
erythromycin (if macrolide needed in pregnancy; consider benefit/harm) 250mg to 500mg QDS for 5 to 7 days
If MRSA suspected or confirmed – consult local microbiologist.
For information on children’s dosage or for detailed information see the guidance visual summary or https://www.nice.org.uk/guidance/ng190
Section last updated March 2021Impetigo
Localised non-bullous impetigo:
Hydrogen peroxide 1% cream (other topical antiseptics are available but no evidence for impetigo).
If hydrogen peroxide unsuitable or ineffective, short-course topical antibiotic.
Widespread non-bullous impetigo:
Short-course topical or oral antibiotic.
Take account of person’s preferences, practicalities of administration, previous use of topical antibiotics because antimicrobial resistance can develop rapidly with extended or repeated use, and local antimicrobial resistance data.
Bullous impetigo, systemically unwell, or high risk of complications:
Short-course oral antibiotic.
Do not offer combination treatment with a topical and oral antibiotic to treat impetigo.
Topical antiseptic:
hydrogen peroxide 1% BD or TDS for 5 days
5 days treatment is appropriate for most, but can be increased to 7 days based on clinical judgement
Topical antibiotic:
First choice:
fusidic acid 2% TDS for 5 days
5 days treatment is appropriate for most, but can be increased to 7 days based on clinical judgement
Fusidic acid resistance suspected or confirmed:
mupirocin 2% TDS for 5 days
5 days treatment is appropriate for most, but can be increased to 7 days based on clinical judgement
Oral antibiotic:
First choice in adults:
flucloxacillin 500mg QDS for 5 days
5 days treatment is appropriate for most, but can be increased to 7 days based on clinical judgement
see guidance visual summary for child dosage
Penicillin allergy or flucloxacillin unsuitable in adults:
clarithromycin 250mg BD for 5 days
5 days treatment is appropriate for most, but can be increased to 7 days based on clinical judgement
see guidance visual summary for child dosage
OR
erythromycin (if macrolide needed in pregnancy; consider benefit/harm) 250 to 500mg QDS for 5 days
5 days treatment is appropriate for most, but can be increased to 7 days based on clinical judgement
see guidance visual summary for child dosage
If MRSA suspected or confirmed – consult local microbiologist
For information on children’s dosage or for detailed information click the guidance visual summary or https://www.nice.org.uk/guidance/ng153
Section last updated February 2020
Insect Bites and Stings
Most insect bites or stings will not need antibiotics.
Do not offer an antibiotic if there are no symptoms or signs of infection.
If there are symptoms or signs of infection, see cellulitis and erysipelas.
For detailed information see the guidance visual summary or https://www.nice.org.uk/guidance/ng182
Section last updated Oct 2023
Leg Ulcer Infection
Manage any underlying conditions to promote ulcer healing.
Only offer an antibiotic when there are symptoms or signs of infection (such as redness or swelling spreading beyond the ulcer, localised warmth, increased pain or fever). Few leg ulcers are clinically infected, but most are colonised by bacteria.
When prescribing antibiotics, take account of severity, risk of complications and previous antibiotic use.
First-choice in adults:
flucloxacillin 500mg to 1g QDS for 7 days
Penicillin allergy or if flucloxacillin unsuitable in adults:
doxycycline 200mg on day 1, then 100mg OD (can be increased to 200mg daily) for 7 days
OR
clarithromycin 500mg BD for 7 days
OR
erythromycin (if macrolide needed in pregnancy; consider benefit/harm) 500mg QDS for 7 days
Second choice in adults:
co-amoxiclav 500/125mg TDS for 7 days
OR
co-trimoxazole (in penicillin allergy) 960mg BD for 7 days
For antibiotic choices if severely unwell or MRSA suspected or confirmed, click on the visual summary
For information on children’s dosage or for detailed information see the guidance visual summary or https://www.nice.org.uk/guidance/ng152
Section last updated Feb 2020Cellulitis and Erysipelas
Exclude other causes of skin redness (inflammatory reactions or non-infectious causes).
Consider marking extent of infection with a single-use surgical marker pen.
Offer an antibiotic. Take account of severity, site of infection, risk of uncommon pathogens, any microbiological results and MRSA status.
Infection around eyes or nose is more concerning because of serious intracranial complications.
Do not routinely offer antibiotics to prevent recurrent cellulitis or erysipelas.
First choice:
Flucloxacillin (adults) 500mg to 1g QDS for 5 to 7 days
A longer course (up to 14 days total) may be needed but skin takes time to return to normal, and full resolution at 5 to 7 days is not expected.
see the guidance visual summary for child dosage
Penicillin allergy or if flucloxacillin unsuitable:
clarithromycin (adults) 500mg BD for 5 to 7 days
A longer course (up to 14 days total) may be needed but skin takes time to return to normal, and full resolution at 5 to 7 days is not expected.
see the guidance visual summary for child dosage
OR
erythromycin (adults) (if macrolide needed in pregnancy; consider benefit/harm) 500mg QDS 5 to 7 days
A longer course (up to 14 days
total) may be needed but skin takes time to return to normal, and full
resolution at 5 to 7 days is not expected
see the guidance visual summary for child dosage
OR
doxycycline (adults only) 200mg on day 1, then 100mg OD 5 to 7 days
A longer course (up to 14 days total) may be needed but skin takes time to return to normal, and full resolution at 5 to 7 days is not expected.
OR
co-amoxiclav (children only: not in penicillin allergy) 5 to 7 days
A longer course (up to 14 days total) may be needed but skin takes time to return to normal, and full resolution at 5 to 7 days is not expected.
see the guidance visual summary for child dosage
If infection near eyes or nose:
co-amoxiclav (adults) 500/125mg TDS for 7 days
A longer course (up to 14 days total) may be needed but skin takes time to return to normal, and full resolution at 5 to 7 days is not expected.
see the guidance visual summary for child dosage
If infection near eyes or nose (penicillin allergy):
clarithromycin (adults) 500mg BD for 7 days
A longer course (up to 14 days total) may be needed but skin takes time to return to normal, and full resolution at 5 to 7 days is not expected.
WITH
metronidazole (adults) (only add in children if anaerobes suspected) 400mg TDS for 7 days
A longer course (up to 14 days total) may be needed but skin takes time to return to normal, and full resolution at 5 to 7 days is not expected.
see the guidance visual summary for child dosage
For alternative choice antibiotics for severe infection, suspected or confirmed MRSA infection and IV antibiotics click on the visual summary. For information on children’s dosage or for detailed information click the visual summary icon.
Section last updated Sept 2019
Diabetic Foot Infection
In diabetes, all foot wounds are likely to be colonised with bacteria. Diabetic foot infection has at least 2 of: local swelling or induration; erythema; local tenderness or pain; local warmth; purulent discharge.
Severity is classified as:
- Mild: local infection with 0.5 to less than 2cm erythema
- Moderate: local infection with more than 2cm erythema or involving deeper structures (such as abscess, osteomyelitis, septic arthritis or fasciitis)
- Severe: local infection with signs of a systemic inflammatory response.
Start antibiotic treatment as soon as possible.
Take samples for microbiological testing before, or as close as possible to, the start of treatment.
When choosing an antibiotic, take account of severity, risk of complications, previous microbiological results and antibiotic use, and patient preference.
Do not offer antibiotics to prevent diabetic foot infection.
Mild infection: adult first choice
flucloxacillin 500mg to 1g QDS for 7 days*
Mild infection: adult penicillin allergy
clarithromycin 500mg BD for 7 days*
OR
erythromycin (if macrolide needed in pregnancy; consider benefit/harm) 500mg QDS for 7 days*
OR
doxycycline 200mg on day 1, then 100mg OD (can be increased to 200mg daily) for 7 days*
*A longer course (up to a further 7 days) may be needed based on clinical assessment. However, skin does take time to return to normal, and full resolution at 7 days is not expected.
For antibiotic choices for moderate or severe infection, infections where Pseudomonas aeruginosa or MRSA is suspected or confirmed, and IV antibiotics see the guidance visual summary.
For information on children’s dosage or for detailed information see the guidance visual summary or https://www.nice.org.uk/guidance/ng19/
Section last updated Oct 2019
Acne Vulgaris
First-line treatment options: offer a course of 1 of the options, taking account of severity, preferences, and advantages/disadvantages of each option. Completing the course is important because positive effects can take 6 to 8 weeks.
Consider topical benzoyl peroxide monotherapy as an alternative if first-line treatment options are contraindicated, or to avoid topical retinoids or an antibiotic (topical or oral).
Do not use: monotherapy with a topical antibiotic, monotherapy with an oral antibiotic, or a combination of a topical antibiotic and an oral antibiotic.
Review first-line treatment at 12 weeks.
Only continue a topical or oral antibiotic for more than 6 months in exceptional circumstances. Review at 3 monthly intervals and stop the antibiotic as soon as possible.
First line: for any acne severity, not in under 9s
fixed combination of topical adapalene with topical benzoyl peroxide
0.1% adapalene/ 2.5% benzoyl peroxide or 0.3% adapalene/2.5% benzoyl peroxide OD (thinly applied in the evening) for 12 weeks
OR
for any acne severity, not in under 12s
fixed combination of topical tretinoin with topical clindamycin
0.025% tretinoin/ 1% clindamycin OD (thinly applied in the evening) for 12 weeks
OR
for mild to moderate acne, not in under 12s
fixed combination of topical benzoyl peroxide with topical clindamycin
3% benzoyl peroxide/1% clindamycin or 5% benzoyl peroxide/1% clindamycin OD (thinly applied in the evening) for 12 weeks
OR
for moderate to severe acne, not in under 12s
fixed combination of topical adapalene with topical benzoyl peroxide AND either oral lymecycline or oral doxycycline
either 0.1% adapalene/ 2.5% benzoyl peroxide or 0.3% adapalene/2.5% benzoyl peroxide OD (thinly applied in the evening) AND either oral lymecycline 408mg or oral doxycycline 100mg OD for 12 weeks
OR
for moderate to severe acne, not in under 12s
topical azelaic acid AND either oral lymecycline or oral doxycycline
15% or 20% azelaic acid BD AND either lymecycline 408mg or doxycycline 100mg OD for 12 weeks
Alternative: topical benzoyl peroxide 5% benzoyl peroxide OD to BD for 12 weeks
For information on children’s dosage or for detailed information see the NICE guidance.
Section last updated June 2021
Human and Animal Bites
Offer an antibiotic for a human or animal bite if there are symptoms or signs of infection, such as increased pain, inflammation, fever, discharge or an unpleasant smell. Take a swab for microbiological testing if there is discharge (purulent or non-purulent) from the wound.
Do not offer antibiotic prophylaxis if a human or animal bite has not broken the skin.
Human bite: Offer antibiotic prophylaxis if the human bite has broken the skin and drawn blood.
Consider antibiotic prophylaxis if the human bite has broken the skin but not drawn blood if it is in a high-risk area or person at high risk.
Cat bite: Offer antibiotic prophylaxis if the cat bite has broken the skin and drawn blood.
Consider antibiotic prophylaxis if the cat bite has broken the skin but not drawn blood if the wound could be deep.
Dog or other traditional pet bite (excluding cat bite): Do not offer antibiotic prophylaxis if the bite has broken the skin but not drawn blood.
Offer antibiotic prophylaxis if the bite has broken the skin and drawn blood if it has caused considerable, deep tissue damage or is visibly contaminated (for example, with dirt or a tooth).
Consider antibiotic prophylaxis if the bite has broken the skin and drawn blood if it is in a high-risk area or person at high risk.
First choice:
co-amoxiclav (in adults) 250/125mg or 500/125mg TDS for 3 days for prophylaxis, 5 days for treatment*
see the visual summary for child dosage
Penicillin allergy or co-amoxiclav unsuitable (in those over 12 years):
doxycycline 200mg on day 1, then 100mg or 200mg daily for 3 days for prophylaxis, 5 days for treatment*
WITH
metronidazole 400mg TDS for 3 days for prophylaxis, 5 days for treatment*
seek specialist advice in pregnancy
see the visual summary for other management options and dosage in children
IV antibiotics: check visual summary
*course length can be increased to 7 days (with review) based on clinical assessment of the wound.
For information on children’s dosage or for detailed information click the visual summary icon.
Section last updated Oct 2023