Skin Infections Treatment summaries

Question 1

Impetigo

Answer 1

In patients with localised non-bullous impetigo who are not systemically unwell or at high risk of complications, consider hydrogen peroxide 1% cream; if unsuitable (e.g. if impetigo is around the eyes), offer a topical antibacterial.

In patients with widespread non-bullous impetigo who are not systemically unwell or at high risk of complications, offer a topical or oral antibacterial

Topical first line if hydrogen peroxide unsuitable or ineffective:
fusidic acid.
Alternative if fusidic acid resistance suspected or confirmed: mupirocin.
Oral first line:
Flucloxacillin.
Alternative if penicillin allergy or flucloxacillin unsuitable: clarithromycin or erythromycin (in pregnancy).

Question 2

Cellulitis

Answer 2

Oral or Intravenous first line:
Flucloxacillin.
Alternative in penicillin allergy or flucloxacillin unsuitable: clarithromycin, oral erythromycin (in pregnancy), or oral doxycycline.
Oral or Intravenous first line if infection near the eyes or nose:
Co-amoxiclav.
Alternative in penicillin allergy or co-amoxiclav unsuitable: clarithromycin with metronidazole.

Alternative if infection is severe
Oral or Intravenous:
Co-amoxiclav, clindamycin, intravenous cefuroxime, or intravenous ceftriaxone (ambulatory care only).
If meticillin-resistant Staphylococcus aureus confirmed or suspected, add intravenous vancomycin, intravenous teicoplanin, or linezolid (specialist use only if vancomycin or teicoplanin cannot be used).
For ambulatory care, and in MRSA confirmed or suspected infections, other antibacterials may be appropriate based on microbiological results and specialist advice.

Question 3

Leg ulcer

Answer 3

Non-severely unwell patients
Oral first line:
Flucloxacillin.
Alternative in penicillin allergy or flucloxacillin unsuitable: doxycycline, clarithromycin, or erythromycin (in pregnancy).
Oral second line (guided by microbiological results when available):
Co-amoxiclav.
Alternative in penicillin allergy: co-trimoxazole [unlicensed].
Severely unwell patients
Oral or Intravenous first line (guided by microbiological results if available):
Intravenous flucloxacillin with or without intravenous gentamicin and/or metronidazole, or intravenous co-amoxiclav with or without intravenous gentamicin.
Alternative in penicillin allergy: intravenous co-trimoxazole [unlicensed] with or without intravenous gentamicin and/or metronidazole.
Oral or Intravenous second line (guided by microbiological results when available or following specialist advice):
Intravenous piperacillin with tazobactam, or intravenous ceftriaxone with or without metronidazole.
Antibacterials to be added if meticillin-resistant Staphylococcus aureus (MRSA) infection suspected or confirmed
Oral or Intravenous (in addition to antibacterials listed above):
Intravenous vancomycin, intravenous teicoplanin, or linezolid (specialist use only if vancomycin or teicoplanin cannot be used).

Question 3

infected bite/bite prophylaxis

Answer 3

Oral first line:
Co-amoxiclav.
Alternative in penicillin allergy or co-amoxiclav unsuitable: doxycycline with metronidazole; seek specialist advice in pregnancy.
Intravenous first line:
Co-amoxiclav.
Alternative in penicillin allergy or co-amoxiclav unsuitable: cefuroxime or ceftriaxone, with metronidazole; seek specialist advice if a cephalosporin is not appropriate.

Question 4

Secondary infection of eczema

Answer 4

Topical first line:
Fusidic acid.
If fusidic acid unsuitable or ineffective: offer an oral antibacterial.
Oral first line:
Flucloxacillin.
Alternative if penicillin allergy or flucloxacillin unsuitable: clarithromycin or erythromycin (in pregnancy).

Question 6

Mastitis

Answer 6

Flucloxacillin
Suggested duration of treatment 10–14 days.
If penicillin-allergic, erythromycin
Suggested duration of treatment 10–14 days.