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For recurrent boils and cellulitis, always send swabs for culture with as much clinical information as possible. This will aid identification of infections caused by Panton-Valentine Leukocidin (PVL) toxin producing Staph aureus. Risk factors include: nursing homes, contact sports, sharing equipment & eczema.
Invasive Group A Streptococcal infections have increased in incidence and need to be assessed rapidly in hospital. Maintain a high index of suspicion in patients with a high fever, severe muscle aches, confusion, unexplained D&V, local muscle tenderness, or severe pain out of proportion to external signs, hypotension, a flat red rash over large area of the body, conjuctival suffusion.
The information below is based on NICE NG153 Impetigo: antimicrobial prescribing (February 2020).
Impetigo is a contagious, bacterial infection of the superficial layers of the skin. Impetigo affects all age groups; however, it is most common in young children.
Advise people with impetigo, and their parents or carers if appropriate, about good hygiene measures to reduce the spread of impetigo to other areas of the body and to other people.
Self-care advice:
Do not offer combination treatment with a topical and oral antibiotic to treat impetigo.
Consider hydrogen peroxide 1% cream for people with localised non-bullous impetigo who are not systemically unwell or at high risk of complications, if hydrogen peroxide 1% cream is unsuitable, i.e. if ineffective or if impetigo is around eyes, offer a short course of a topical antibiotic (see below for appropriate choices).
Offer a short course of a topical or oral antibiotic for people with widespread non‑bullous impetigo who are not systemically unwell or at high risk of complications (see below for appropriate choices).
Offer a short course of an oral antibiotic for all people with bullous impetigo, and people with non-bullous impetigo who are systemically unwell or at high risk of complications (see below for appropriate choices).
For people with impetigo that is worsening or has not improved after treatment with hydrogen peroxide 1% cream, offer:
For people with impetigo that is worsening or has not improved after completing a course of topical antibiotics:
For people with impetigo that is worsening or has not improved after completing a course of oral antibiotics, consider sending a skin swab for microbiological testing
For people with impetigo that recurs frequently:
If a skin swab has been sent for microbiological testing:
Reassess at any time if symptoms worsen rapidly or significantly, taking account of:
Refer to hospital:
Consider referral or seeking specialist advice for people with impetigo if they:
Consult local microbiologist if MRSA suspected or confirmed
A 5‑day course is appropriate for most people with impetigo but can be increased to 7 days based on clinical judgement, depending on the severity and number of lesions.
See section 13.11.5 Oxidisers and dyes
See section 13.10.1 Antibacterial preparations
MRSA infection in impetigo is rare, consult local microbiologist if MRSA suspected or confirmed prior to consideration of topical mupirocin
See sections 5.1.1 Penicillins and 5.1.5 Macrolides
A 5‑day course is appropriate for most people with impetigo but can be increased to 7 days based on clinical judgement, depending on the severity and number of lesions.
See section 13.11.5 Oxidisers and dyes
See section 13.10.1 Antibacterial preparations
MRSA infection in impetigo is rare, consult local microbiologist if MRSA suspected or confirmed prior to consideration of topical mupirocin
See sections 5.1.1 Penicillins and 5.1.5 Macrolides
The information below is based on NICE NG190: Secondary bacterial infection of eczema and other common skin conditions: antimicrobial prescribing (March 2021).
Manage underlying eczema and flares with treatments such as emollients and topical corticosteroids, whether antibiotics are offered or not. See here for Management of eczema.
Symptoms and signs of infected eczema include weeping, pustules, crusts, no response to treatment, rapidly worsening eczema, fever, and malaise.
Not all eczema flares are caused by a bacterial infection, so will not respond to antibiotics, even if weeping and crusts are present. Eczema is often colonised with bacteria but may not be clinically infected. Eczema can also be infected with herpes simplex virus (eczema herpeticum).
Do not routinely take a skin swab for microbiological testing in people with infected eczema at the initial presentation.
In people who are not systemically unwell, do not offer either a topical or oral antibiotic for infected eczema, take into account:
If an antibiotic is offered to people who are not systemically unwell with infected eczema, when choosing between a topical or oral antibiotic, take into account:
If an antibiotic is given, advise the person (and their parents and carers as appropriate):
Do not routinely offer either a topical or oral antibiotic for infected eczema in people who are not systemically unwell
If treatment is appropriate, a 5-day course is suitable for most people with infected eczema but can be increased to 7 days based on clinical judgement, depending on severity
Do not routinely offer either a topical or oral antibiotic for infected eczema in people who are not systemically unwell
If treatment is appropriate, a 5-day course is suitable for most people with infected eczema but can be increased to 7 days based on clinical judgement, depending on severity
Reassess people with infected eczema if:
When reassessing people with secondary bacterial infection of eczema, take account of:
For people with secondary bacterial infection of eczema that is worsening or has not improved as expected, consider sending a skin swab for microbiological testing.
For people with secondary bacterial infection of eczema that recurs frequently:
If a skin swab has been sent for microbiological testing:
Refer people with secondary bacterial infection of eczema to hospital if they have any symptoms or signs suggesting a more serious illness or condition, such as rigors, diarrhoea and vomiting, spreading erythema (sunburn rash), conjunctival redness (streptococcus or staphylococcus toxic shock), necrotising fasciitis (agonising pain out of proportion to what can be seen) or sepsis.
Consider referral or seeking specialist advice for people with secondary bacterial infection of eczema if they:
Consult local microbiologist if MRSA suspected or confirmed.
Please see local referral guideline if severe and recurrent eczema:
Discuss with a Microbiologist if exposure to river or sea-water.
Inflammation about leg ulcers is often mistaken for cellulitis. There is no evidence that swabbing leg ulcers routinely or treating them with antibiotics is useful unless there is genuine ascending cellulitis.
Bilateral cellulitis is rare and may require a re-evaluation of diagnosis. A low CRP may suggest a non-infectious aetiology in difficult cases.
Swabbing of any broken skin, or between toes for foot cellulitis, may be helpful if done prior to starting antibiotics.
A nose swab should be collected to look for MRSA carriage if the patient has been in hospital recently.
The formulary gives dose and duration of treatment for adults unless stated otherwise.
If severe and/or failure with suitable oral antibiotics consider outpatient IV antibiotics. Eligible patients are those who are haemodynamically stable and with no unstable co-morbidities.
Plymouth: Liaise with Acute GP service
Torbay: Liaise with Ambulatory Care or discuss with on call Microbiologist
If the cellulitis is clearly not associated with mucosal structures such as the facial sinuses or teeth then treat as standard cellulitis, see above. If mucosal facial structures are involved use co-amoxiclav.
Have a low threshold for referral in the event of signs and symptoms suggesting orbital involvement, for example
Ulcers are always colonised.
Culture swabs and antibiotics are only indicated if cellulitis is present. Treat with cellulitis regimen (see above).
Antibiotics should only be used in active infection (increased pain, pyrexia, erythema beyond 2cm, localised heat). If antibiotics given, review with culture results.
Please refer to: Methicillin Resistant Staphylococcus Aureus (MRSA) guidance
An MHRA patient information leaflet is available on the Public Health England (HPA) website
Human bites: Thorough irrigation is import. Assess risk of tetanus, HIV, hepatitis B&C- follow inoculation policy. Antibiotic prophylaxis is advised.
Cat / dog / bat bites: Assess risk of tetanus and rabies- follow inoculation policy.
Give prophylaxis if:
The formulary gives dose and duration of treatment for adults unless stated otherwise.
625mg every 8 hours for 7 days
If penicillin allergic
For children allergic to penicillin and unable to take co-amoxiclav, discuss with microbiologist
Treat all home & sexual contacts within 24 hours.
Application notes
If allergy
The use of OTC dusting powders can be recommended to help prevent re-infection of athlete's foot.
NHS England (NHSE) has published new prescribing guidance for various common conditions for which over-the-counter (OTC) items should not be routinely prescribed in primary care (quick reference guide). These conditions include ringworm and athlete's foot.
Many of these products are cheap to buy and are readily available OTC along with advice from pharmacies. Some self-care medicines are available from shops and supermarkets. Please click here for further information, exceptions, and a patient leaflet.
Oral therapy is indicated in scalp infection, discuss with specialist.
Terbinafine is fungicidal and the treatment time is shorter than with fungistatic imidazoles.
Take skin scrapings for culture for intractable infections, and if infection confirmed consider oral terbinafine/ itraconazole.
Take nail clippings and only start therapy if infection is confirmed by laboratory.
Oral terbinafine is more effective than oral azoles (fungicidal agent). Idiosyncratic liver reactions occur rarely with terbinafine.
Pulsed itraconazole monthly is recommended for infections with candida and non-dermatophyte moulds.
NHS England (NHSE) has published new prescribing guidance for various common conditions for which over the counter (OTC) items should not be routinely prescribed in primary care (quick reference guide). One of these conditions is infrequent cold sores of the lip.
A number of products containing antivirals are cheap to buy and are readily available OTC along with advice from pharmacies. Some self-care medicines are available from shops and supermarkets. Please click here for further information, exceptions, and a patient leaflet.
Cold sores resolve after 7–10 days without treatment.
Topical antivirals applied prodromally reduce duration by 12-24 hours
Thorough irrigation is recommended. Drinkable tap water, boiled and cooled water, and normal saline are all comparable wound cleansing agents. Assess risk of tetanus.
Antibiotic therapy is usually not indicated unless:
In these cases prompt irrigation and co-amoxiclav 625mg every 8 hours for 5 days.
If symptoms and signs of infection develop after closure of the laceration: