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.

Treatment

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:

• the evidence, which suggests a limited benefit with antibiotics in addition to topical corticosteroids compared with topical corticosteroids alone
• the risk of antimicrobial resistance with repeated courses of antibiotics
• the extent and severity of symptoms or signs
• the risk of developing complications, which is higher in people with underlying conditions such as immunosuppression.

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:

• their preferences (and those of their parents and carers as appropriate) for topical or oral administration
• the extent and severity of symptoms or signs (a topical antibiotic may be more appropriate if the infection is localised and not severe; an oral antibiotic may be more appropriate if the infection is widespread or severe)
• possible adverse effects
• previous use of topical antibiotics because antimicrobial resistance can develop rapidly with extended or repeated use.

Advice

If an antibiotic is given, advise the person (and their parents and carers as appropriate):

• about possible adverse effects
• about the risk of developing antimicrobial resistance with extended or repeated use
• that they should continue treatments such as emollients and topical corticosteroids
• that it can take time for secondary bacterial infection of eczema to resolve, and full resolution is not expected until after the antibiotic course is completed
• to seek medical help if symptoms worsen rapidly or significantly at any time.

Antimicrobials for adults aged 18 years and over

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

Topical antibiotic

Fusidic acid 2% cream/ointment

• Apply three times a day for 5 days
• If infection does not improve consider:
  • allergy to fusidic acid
  • alternative infection (i.e. scabies, HSV)
  • sending a skin swab for microbiological testing
• See section 13.10.1. Antibacterial preparations

Oral antibiotic

Flucloxacillin

• 500mg four times a day for 5 days
• See section 5.1.1 Penicillins

Oral antibiotic (penicillin allergy)

Clarithromycin

• 250mg to 500mg twice a day for 5 days
• 500mg twice a day for 5 days if severe infection
• See section 5.1.5 Macrolides

OR

Doxycycline

• 200mg single dose stat then 100mg once or twice a day for a total of 5 days
• Local recommendation; not included in NICE NG190
• See section 5.1.3 Tetracyclines

Oral antibiotic (penicillin allergy in pregnancy)

Erythromycin

• 250mg to 500mg four times a day for 5 days
• 500mg twice a day for 5 days if severe infection
• See section 5.1.5 Macrolides

Antimicrobials for children and young people under 18 years

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

Topical antibiotic

Fusidic acid 2% cream/ointment

• Apply three times a day for 5 days
• If infection does not improve consider:
  • allergy to fusidic acid
  • alternative infection (i.e. scabies, HSV)
  • sending a skin swab for microbiological testing
• See section 13.10.1. Antibacterial preparations

Oral antibiotic

Flucloxacillin

• Children 1 month to 17 years of age (doses given four times a day for 5 days):
  • 1 month to 1 year: 62.5mg to 125mg
  • 2 to 9 years: 125mg to 250mg
  • 10 to 17 years: 250mg to 500mg
• See section 5.1.1 Penicillins

Oral antibiotic (penicillin allergy)

Clarithromycin

• Children 1 month to 11 years of age (doses given twice daily for 5 days):
  • Body-weight under 8 kg: 7.5mg/kg
  • Body-weight 8-11 kg: 62.5mg
  • Body-weight 12-19 kg: 125mg
  • Body-weight 20-29 kg: 187.5mg
  • Body-weight 30-40 kg: 250mg
• Children 12 years to 17 years of age:
  • 250mg to 500mg twice a day for 5 days
  • 500mg twice a day for 5 days if severe infection
• See section 5.1.5 Macrolides

OR

Doxycycline

• Children 12 years to 17 years:
  • 200mg single dose stat then 100mg once or twice a day for a total of 5 days
• Local recommendation; not included in NICE NG190
• See section 5.1.3 Tetracyclines

Oral antibiotic (penicillin allergy in pregnancy)

Erythromycin

• Children 8 years to 17 years:
  • 250mg to 500mg four times a day for 5 days
  • 500mg twice a day for 5 days if severe infection
• See section 5.1.5 Macrolides

Reassessment and referral

Reassess people with infected eczema if:

• they become systemically unwell or have pain that is out of proportion to the infection
• their symptoms worsen rapidly or significantly at any time
• their symptoms have not improved after completing a course of antibiotics.

When reassessing people with secondary bacterial infection of eczema, take account of:

• other possible diagnoses, such as eczema herpeticum
• any symptoms or signs suggesting a more serious illness or condition, such as cellulitis, necrotising fasciitis (agonising pain out of proportion to what can be seen) or sepsis
• previous antibiotic use, which may have cause resistant bacteria.

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:

• send a skin swab for microbiological testing and
• consider taking a nasal swab and starting treatment for decolonisation.

If a skin swab has been sent for microbiological testing:

• review the choice of antibiotic when results are available and
• change the antibiotic according to results if symptoms are not improving, using a narrow-spectrum antibiotic is possible.

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:

• have spreading infection that is not responding to oral antibiotics
• are systemically unwell
• are at high risk of complications
• have infections that recur frequently.

Consult local microbiologist if MRSA suspected or confirmed.

Please see local referral guideline if severe and recurrent eczema:

• South Devon and Torbay
  
• Western locality