Gastroenteritis
NI. (Frequently self-limiting, may not be bacterial)
Campylobacter enteritis
NI unless immunocompromised or severe infection -
Clarithro-, azithro-, OR erythro- mycin.
ALT: ciprofloxacin.
Clarithro-, azithro-, OR erythro- mycin.
ALT: ciprofloxacin.
Salmonella (non-typhoid)
NI unless immunocompromised or severe infection -
Ciprofloxacin OR
cefotaxime.
Ciprofloxacin OR
cefotaxime.
Shigellosis
Only treat if more than mild -
Ciprofloxacin OR
azithromycin
ALT (if sens): Amoxicillin OR trimethoprim
Ciprofloxacin OR
azithromycin
ALT (if sens): Amoxicillin OR trimethoprim
Typhoid fever
Multi-resistant (test sensitivity)
Cefotaxime or ceftriaxone
ALT: Azithromycin OR ciprofloxacin (if sens)
Cefotaxime or ceftriaxone
ALT: Azithromycin OR ciprofloxacin (if sens)
Clostridium difficile
Oral metronidazole (10-14 days) OR
(for 3rd or severe infection) oral vancomycin (10-14 days)
IF (not responding or very severe) add IV metronidazole
(for 3rd or severe infection) oral vancomycin (10-14 days)
IF (not responding or very severe) add IV metronidazole
Biliary-tract infection
Ciprofloxacin OR
gentamicin OR
a cephalosporin
gentamicin OR
a cephalosporin
Peritonitis
A cephalosprin + metronidazole OR
gentamicin + metronidazole OR
gentamicin + clindamycin OR
piperacillin with tazobactam (tazocin) alone
gentamicin + metronidazole OR
gentamicin + clindamycin OR
piperacillin with tazobactam (tazocin) alone
Endocarditis: initial 'blind' therapy
(Flucloxacillin OR benzylpenicillin if less severe) + Gentamicin
ALT (if resistant, or prostheses present): vancomycin + rifampicin + gentamicin
ALT (if resistant, or prostheses present): vancomycin + rifampicin + gentamicin
Endocarditis caused by staphylococci
Flucloxacillin (4-6 weeks)
Add rifampicin for at least 2 weeks if prosthetic valve endocarditis.
ALT: vancomycin + rifampicin
Add rifampicin for at least 2 weeks if prosthetic valve endocarditis.
ALT: vancomycin + rifampicin
Native-valve endocarditis caused by fully sensitive streptococci
(eg. viridans streptococci)
(eg. viridans streptococci)
Benzylpenicillin (4 weeks)
ALT: vancomycin (4 weeks)
If large/abscess/infected emboli = benzylpenicillin + gentamicin (2 weeks)
ALT: vancomycin (4 weeks)
If large/abscess/infected emboli = benzylpenicillin + gentamicin (2 weeks)
Native-valve endocarditis caused by less-sensitive streptococci.
Benzylpenicillin (4-6 wks) + gentamicin (2 wks)
ALT: 'vancomycin or teicoplanin (4-6 wks)' + gentamicin (2 wks)
ALT: 'vancomycin or teicoplanin (4-6 wks)' + gentamicin (2 wks)
Prosthetic valve endocarditis caused by streptococci.
Benzylpenicillin (6 wks) + gentamicin (2 wks)
ALT: 'vancomycin or teicoplanin (6 wks)' + gentamicin (2 wks)
ALT: 'vancomycin or teicoplanin (6 wks)' + gentamicin (2 wks)
Endocarditis caused by enterococci
(eg. Enterococcus faecalis)
(eg. Enterococcus faecalis)
(Amoxicillin or ampicillin) + gentamicin (4-6 wks)
ALT: (vancomycin or teicoplanin) + gentamicin
IF (gent-resistant): change gent to streptomycin
ALT: (vancomycin or teicoplanin) + gentamicin
IF (gent-resistant): change gent to streptomycin
Endocarditis caused by hameophilus, actinobacillus, cardiobacterium, eikenella, or kingella
('HACEK' organisms)
('HACEK' organisms)
(Amoxicillin or ampicillin '4-6 wks') + low-dose gentamicin (2 wks)
IF (amoxi-resistant): change amoxi to ceftriaxone
IF (amoxi-resistant): change amoxi to ceftriaxone
Haemophilus influenzae epiglottitis
Cefotaxime OR
ceftriaxone
ALT: chloramphenicol
ceftriaxone
ALT: chloramphenicol
Chronic bronchitis: acute exacerbations
(Amoxicillin or ampicillin) '5 days' OR
a tetracycline '5 days'
ALT: (clarithro-, erythro-, or azithro- mycin) '5 days'
a tetracycline '5 days'
ALT: (clarithro-, erythro-, or azithro- mycin) '5 days'
Community-acquired pneumonia
(low-severity)
(low-severity)
Amoxicillin or ampicillin (7 days, 14-21 for staph)
IF (atypical), add (clarithro-, erythro-, or azithro- mycin)
ALT: doxycline OR (clarithro-, erythro-, or azithro- mycin)
IF (atypical), add (clarithro-, erythro-, or azithro- mycin)
ALT: doxycline OR (clarithro-, erythro-, or azithro- mycin)
Community-acquired pneumonia
(moderate-severity)
(moderate-severity)
(Amoxicillin or ampicillin) + (clarithro-, erythro-, or azithro- mycin) '7 days, 14-21 for staph' OR
doxycycline alone
IF (MRSA), add (vancomycin or teicoplanin)
doxycycline alone
IF (MRSA), add (vancomycin or teicoplanin)
Community-acquired pneumonia
(high severity)
(high severity)
Benzylpenicillin + (clarithro-, erythro-, or azithro- mycin) '7-10 days, 14-21 for staph' OR
Benzylpenicillin + doxycycline
ALT: (cefuroxime or cefotaxime or ceftriaxone) + (clarithro-, erythro-, or azithro- mycin).
IF (life-threat, gram-neg, or nursing home): Co-amoxiclav + (clarithro-, erythro-, or azithro- mycin)
IF (MRSA), add (vancomycin or teicoplanin)
Benzylpenicillin + doxycycline
ALT: (cefuroxime or cefotaxime or ceftriaxone) + (clarithro-, erythro-, or azithro- mycin).
IF (life-threat, gram-neg, or nursing home): Co-amoxiclav + (clarithro-, erythro-, or azithro- mycin)
IF (MRSA), add (vancomycin or teicoplanin)
Pneumonia caused by atypical pathogens
(eg. legionella, chlamydial, mycoplasma)
(eg. legionella, chlamydial, mycoplasma)
(Clarithro-, erythro-, or azithro- mycin) '14 days'
ALT: a quinolone (for legionella), or doxycyline (for chlamydial/mycoplasma)
ALT: a quinolone (for legionella), or doxycyline (for chlamydial/mycoplasma)
Pneumonia caused by legionella
(Clarithro-, erythro-, or azithro- mycin) '7-10 days'
ALT: a quinolone (eg. ciprofloxacin)
IF (high severity), add (Clarithro-, erythro-, or azithro- mycin) OR rifampicin for first few days
ALT: a quinolone (eg. ciprofloxacin)
IF (high severity), add (Clarithro-, erythro-, or azithro- mycin) OR rifampicin for first few days
Pneumonia caused by chlamydial or mycoplasma
(Clarithro-, erythro-, or azithro- mycin) '14 days'
ALT: doxycycline
ALT: doxycycline
Hospital-acquired pneumonia
(early-onset, within 5 days after admission)
(early-onset, within 5 days after admission)
Co-amoxiclav (7 days) OR
cefuroxime (7 days)
IF (life-threat, recent abx, or resistant) treat as late-onset
cefuroxime (7 days)
IF (life-threat, recent abx, or resistant) treat as late-onset
Hospital-acquired pneumonia
(late-onset, after 5 days post-admission)
(late-onset, after 5 days post-admission)
An antipseudomonal penicillin (eg. tazocin) '7 days' OR
broad-spectrum cephalosporin (eg. ceftazidime) OR
another antipseudomonal beta-lactam OR
a quinolone (eg. ciprofloxacin)
IF (MRSA): add vancomycin
IF (pseudomonas aeruginosa): consider adding aminoglycoside (eg. amikacin, gentamicin)
broad-spectrum cephalosporin (eg. ceftazidime) OR
another antipseudomonal beta-lactam OR
a quinolone (eg. ciprofloxacin)
IF (MRSA): add vancomycin
IF (pseudomonas aeruginosa): consider adding aminoglycoside (eg. amikacin, gentamicin)
Meningitis
(initial empirical therapy)
(initial empirical therapy)
Transfer to hospital urgently.
Benzylpenicillin 1.2g (IM/IV) immediately
ALT: cefotaxime or chloramphenicol
Benzylpenicillin 1.2g (IM/IV) immediately
ALT: cefotaxime or chloramphenicol
Meningitis (unknown cause)
(in hospital, in 3 month old to 50 year old.)
(in hospital, in 3 month old to 50 year old.)
(Cefotaxime or ceftriaxone) 'at least 10 days'
IF (recent abx, travel outside UK): consider adding vancomycin.
Consider adjunctive dexamethasone.
IF (recent abx, travel outside UK): consider adding vancomycin.
Consider adjunctive dexamethasone.
Meningitis (unknown cause)
(in hospital, in adults over 50yo.)
(in hospital, in adults over 50yo.)
(Cefotaxime or ceftriaxone) + (amoxicillin or ampicillin) 'at least 10 days'
IF (recent abx, travel outside UK): consider adding vancomycin.
Consider adjunctive dexamethasone.
IF (recent abx, travel outside UK): consider adding vancomycin.
Consider adjunctive dexamethasone.
Meningitis (caused by meningococci)
(in hospital)
(in hospital)
Benzylpenicillin (7 days) OR
(cefotaxime or ceftriaxone)
ALT: chlorampenhicol
(cefotaxime or ceftriaxone)
ALT: chlorampenhicol
Meningitis (caused by pneumococci)
(in hospital)
(in hospital)
(Cefotaxime or ceftriaxone) '14 days'
IF (penicillin sens): use benzylpencillin instead.
IF (penicillin/cephalosporin resistant): add vancomycin +/- rifampicin.
Consider adjunctive dexamethasone.
IF (penicillin sens): use benzylpencillin instead.
IF (penicillin/cephalosporin resistant): add vancomycin +/- rifampicin.
Consider adjunctive dexamethasone.
Meningitis (caused by Haemophilus influenzae)
(in hospital)
(in hospital)
(Cefotaxime or ceftriaxone) '10 days'
ALT: chloramphenicol
Consider adjunctive dexamethasone.
ALT: chloramphenicol
Consider adjunctive dexamethasone.
Meningitis (caused by Listeria)
(in hospital)
(in hospital)
(Amoxicillin or ampicillin '21 days') + gentamicin (7 days)
ALT: co-trimoxazole '21 days'
ALT: co-trimoxazole '21 days'
Pyelonephritis (acute)
A broad-spectrum cephalosporin '10-14 days' OR
a quinolone (eg. ciprofloxacin) '10-14 days'
a quinolone (eg. ciprofloxacin) '10-14 days'
Prostatitis (acute)
(Ciprofloxacin or ofloxacin) '28 days'
ALT: trimethoprim '28 days'
ALT: trimethoprim '28 days'
Urinary tract infection (lower)
Trimethoprim (7 days) OR
nitrofurantoin (7 days)
ALT: (amoxicillin or ampicillin) OR
oral cephalosporin (eg. cefachlor)
Can treat for just 3 days in uncomplicated female UTIs
nitrofurantoin (7 days)
ALT: (amoxicillin or ampicillin) OR
oral cephalosporin (eg. cefachlor)
Can treat for just 3 days in uncomplicated female UTIs
Bacterial vaginosis
Oral metronidazole (5-7 days)
ALT: topical metronidazole (5 days) OR topical clindamycin (7 days)
ALT: topical metronidazole (5 days) OR topical clindamycin (7 days)
Genital chlamydial infection
(uncomplicated)
(uncomplicated)
Contact tracing recommended.
Azithromycin (single dose) OR
doxycyline (7 days)
ALT: erythromycin (14 days)
Azithromycin (single dose) OR
doxycyline (7 days)
ALT: erythromycin (14 days)
Non-gonococcal urethritis
Contact tracing recommended.
Azithromycin (single dose) OR
doxycyline (7 days)
ALT: erythromycin (14 days)
Azithromycin (single dose) OR
doxycyline (7 days)
ALT: erythromycin (14 days)
Non-specific genital infection
Contact tracing recommended.
Azithromycin (single dose) OR
doxycyline (7 days)
ALT: erythromycin (14 days)
Azithromycin (single dose) OR
doxycyline (7 days)
ALT: erythromycin (14 days)
Gonorrhoea
(uncomplicated)
(uncomplicated)
Contact tracing recommended. Consider chlamydia co-infection.
Azithromycin + IM ceftriaxone (single dose each)
ALT (oral): Cefixime + azithromycin (single dose each)
ALT (if quinolone sens) ciprofloxacin + azithromycin
Azithromycin + IM ceftriaxone (single dose each)
ALT (oral): Cefixime + azithromycin (single dose each)
ALT (if quinolone sens) ciprofloxacin + azithromycin
Pelvic inflammatory disease
Contact tracing recommended.
Doxycyline + metronidazole (14 days) + IM ceftriaxone (single dose) OR
ofloxacin + metronidazole (14 days)
Doxycyline + metronidazole (14 days) + IM ceftriaxone (single dose) OR
ofloxacin + metronidazole (14 days)
Early syphillis
(infection less than 2 years)
(infection less than 2 years)
Contact tracing recommended.
Benzathine benzylpenicillin (single dose)
ALT: doxycyline (14 days) OR
erythromycin (14 days)
Benzathine benzylpenicillin (single dose)
ALT: doxycyline (14 days) OR
erythromycin (14 days)
Late latent syphillis
(asymptomatic infection of more than 2 years)
(asymptomatic infection of more than 2 years)
Contact tracing recommende.
Benzathine benzylpenicillin (once weekly for 2 weeks)
ALT: doxycyline (28 days)
Benzathine benzylpenicillin (once weekly for 2 weeks)
ALT: doxycyline (28 days)
Asymptomatic contacts of patients with infectious syphillis.
Doxycycline (14 days)
Septicaemia
(community-acquired)
(community-acquired)
A broad-spectrum anti-pseudomonal penicillin (eg. tazocin or ticarcillin with clavulanic acid) OR
a broad-spectrum cephalosporin (eg. cefuroxime).
IF (MRSA): add vancomycin or teicoplanin.
IF (anerobic): cefuroxime + metronidazole
IF (resistant): meropenem.
a broad-spectrum cephalosporin (eg. cefuroxime).
IF (MRSA): add vancomycin or teicoplanin.
IF (anerobic): cefuroxime + metronidazole
IF (resistant): meropenem.
Septicaemia
(hospital-acquired)
(hospital-acquired)
A broad-spectrum antipseudomonal beta-lactam antibacterial (e.g. piperacillin with tazobactam, ticarcillin with clavulanic acid, ceftazidime, imipenem with cilastatin, or meropenem).
IF (MRSA): add vancomycin or teicoplanin.
IF (anerobic): cefuroxime + metronidazole
IF (MRSA): add vancomycin or teicoplanin.
IF (anerobic): cefuroxime + metronidazole
Septicaemia
(related to vascular catheter)
(related to vascular catheter)
Consider removing vascular catheter.
(Vancomycin or teicoplanin)
IF (gram-neg): add broad-spectrum antipseudomonal beta-lactam (eg. tazocin).
(Vancomycin or teicoplanin)
IF (gram-neg): add broad-spectrum antipseudomonal beta-lactam (eg. tazocin).
Meningococcal septicaemia
Give immediate dose.
Benzylpenicillin OR
(cefotaxime or ceftriaxone)
ALT: chloramphenicol
Benzylpenicillin OR
(cefotaxime or ceftriaxone)
ALT: chloramphenicol
Osteomyelitis
Seek specialist advice if chronic or prostheses.
Flucloxacillin (6 wks) +/- (fusidic acid or rifampicin '2 wks')
ALT: change fluclox to clindamycin
IF (MRSA): change fluclox to (vancomycin or teicoplanin)
Flucloxacillin (6 wks) +/- (fusidic acid or rifampicin '2 wks')
ALT: change fluclox to clindamycin
IF (MRSA): change fluclox to (vancomycin or teicoplanin)
Septic arthritis
Seek specialist advice if prostheses present.
Flucloxacillin (4-6 wks)
ALT: clindamycin (4-6 wks)
IF (MRSA): (vancomycin or teicoplanin)
IF (gonococcal or gram-neg) (cefotaxime or ceftriaxone)
Flucloxacillin (4-6 wks)
ALT: clindamycin (4-6 wks)
IF (MRSA): (vancomycin or teicoplanin)
IF (gonococcal or gram-neg) (cefotaxime or ceftriaxone)
Purulent conjunctivitis
Chloramphenicol eye drops
Pericoronitis
(gum inflammation around erupting tooth)
(gum inflammation around erupting tooth)
NI unless systemic features or persistent.
Metronidazole (3 days)
ALT: amoxicillihn (3 days)
Metronidazole (3 days)
ALT: amoxicillihn (3 days)
Gingivitis
NI unless systemic features or persistent.
Metronidazole (3 days)
ALT: amoxicillin (3 days)
Metronidazole (3 days)
ALT: amoxicillin (3 days)
Throat infections
(bacterial suspected)
(bacterial suspected)
Consider bacterial if history of valvular heart disease, systemic upset, increased risk (eg. immunosuppressed).
Phenoxymethylpenicillin (10 days)
ALT: (Clarithro-, erythro-, or azithro- mycin) '10 days'
Phenoxymethylpenicillin (10 days)
ALT: (Clarithro-, erythro-, or azithro- mycin) '10 days'
Sinusitis
(bacterial suspected)
(bacterial suspected)
Consider bacterial if persistent and purulent discharge >7 days, severe, or high risk.
(Amoxicillin or ampicillin) '7 days' OR
doxycycline (7 days) OR
(Clarithro-, erythro-, or azithro- mycin) '7 days'
IF (no improvement in 48 hrs): oral co-amoxiclav.
IF (severe) initial IV co-amoxiclav OR cefuroxime
(Amoxicillin or ampicillin) '7 days' OR
doxycycline (7 days) OR
(Clarithro-, erythro-, or azithro- mycin) '7 days'
IF (no improvement in 48 hrs): oral co-amoxiclav.
IF (severe) initial IV co-amoxiclav OR cefuroxime
Otitis externa
Flucloxacillin
ALT: (Clarithro-, erythro-, or azithro- mycin)
IF (pseudomonas): ciprofloxacin OR aminoglycoside (eg. gentamicin)
ALT: (Clarithro-, erythro-, or azithro- mycin)
IF (pseudomonas): ciprofloxacin OR aminoglycoside (eg. gentamicin)
Otitis media
Most caused by viruses, or self-limited. Treat if not improved after 72 hrs or deterioration.
(Amoxicillin or ampicillin) '5 days'
ALT: (Clarithro-, erythro-, or azithro- mycin) '5 days'
IF (no improvement >48 hrs): co-amoxiclav
(Amoxicillin or ampicillin) '5 days'
ALT: (Clarithro-, erythro-, or azithro- mycin) '5 days'
IF (no improvement >48 hrs): co-amoxiclav
Impetigo
(small areas of skin infected)
(small areas of skin infected)
Seek microbiology advice before using topical treatment in hospital.
Topical fusidic acid (7 days)
IF (MRSA): topical mupirocin (7 days)
Topical fusidic acid (7 days)
IF (MRSA): topical mupirocin (7 days)
Impetigo
(widespread infection)
(widespread infection)
Oral flucloxacillin (7 days)
ALT: oral (Clarithro-, erythro-, or azithro- mycin)
IF (streptococci): add phenoxymethylpenicillin
ALT: oral (Clarithro-, erythro-, or azithro- mycin)
IF (streptococci): add phenoxymethylpenicillin
Erysipelas
(streptococcus infection of superficial skin, with well-defined edge)
(streptococcus infection of superficial skin, with well-defined edge)
Phenoxymethylpenicillin (7 days) OR
benzylpenicillin
ALT: clindamycin OR
(Clarithro-, erythro-, or azithro- mycin)
IF (severe): high-dose flucloxacillin
benzylpenicillin
ALT: clindamycin OR
(Clarithro-, erythro-, or azithro- mycin)
IF (severe): high-dose flucloxacillin
Cellulitis
(localized or diffuse inflammation of connective tissue with severe inflammation of dermal and subcutaneous layers of the skin)
(localized or diffuse inflammation of connective tissue with severe inflammation of dermal and subcutaneous layers of the skin)
Flucloxacillin (high-dose)
ALT: clindamycin OR
(Clarithro-, erythro-, or azithro- mycin) OR
(vancomycin or teicoplanin)
IF (gram-neg): broad-spectrum antibacterials
ALT: clindamycin OR
(Clarithro-, erythro-, or azithro- mycin) OR
(vancomycin or teicoplanin)
IF (gram-neg): broad-spectrum antibacterials
Animal and human bites
Consider tetanus vaccination/immunoglobulin +/- rabies prophylaxis. Assess risk of blood-borne viruses.
Co-amoxiclav
ALT: doxycycline + metronidazole
Co-amoxiclav
ALT: doxycycline + metronidazole
Mastitis during breastfeeding
Treat if severe, or persistent >12-24 hrs, or infected.
Flucloxacillin (10-14 days)
ALT: erythromycin (10-14 days)
Continue breastfeeding throughout.
Flucloxacillin (10-14 days)
ALT: erythromycin (10-14 days)
Continue breastfeeding throughout.