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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
Infection of broken skin is common making the patient feel unwell and limiting movement. Clinical signs of infected eczema include weeping, pustules, crusts, fever and malaise, or atopic eczema failing to respond to therapy or rapidly worsening atopic eczema.
Take swabs from infected lesions of atopic eczema only if you suspect microorganisms other than Staphylococcus aureus or if you think antibiotic resistance is relevant. Staphylococcus aureus infection is the commonest cause of acute flare up of atopic eczema and should be treated accordingly.
Explain that topical treatments in open containers can be contaminated with microorganisms and act as a source of infection.
Use oral antibiotics plus appropriate potency topical corticosteroid
Fucidin® H cream (hydrocortisone 1% / fusidic acid 2%)
Fucibet® cream (fusidic acid 2% / betamethasone valerate 0.1%)
Trimovate® cream (clobetasone / oxytetracycline / nystatin)
Antimicrobial and emollient combinations
Ensure appropriate potency of topical corticosteroid is being used. Inadequate control of the underlying atopic eczema is the most frequent cause of repeated infections.
Consider antiseptic emollients / shower / bath preparations (e.g. Dermol® range) to reduce bacterial colonisation.
Suspect if:
Management
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: