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Bites and stings – antimicrobial prescribing

About

What is covered

This NICE Pathway sets out an antimicrobial prescribing strategy for human and animal bites, and insect and spider bites and stings in adults, young people and children aged 72 hours and over. It aims to optimise antibiotic use and reduce antibiotic resistance.

Updates

Updates to this NICE Pathway

4 November 2020 Human and animal bites: antimicrobial prescribing (NICE guideline NG184) added.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Short Text

Everything NICE has said on antimicrobial prescribing for bites and stings in an interactive flowchart

What is covered

This NICE Pathway sets out an antimicrobial prescribing strategy for human and animal bites, and insect and spider bites and stings in adults, young people and children aged 72 hours and over. It aims to optimise antibiotic use and reduce antibiotic resistance.

Updates

Updates to this NICE Pathway

4 November 2020 Human and animal bites: antimicrobial prescribing (NICE guideline NG184) added.

Sources

NICE guidance and other sources used to create this interactive flowchart.

Quality standards

Quality statements

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

NICE has produced resources to help implement its guidance on:

Information for the public

NICE has written information for the public on each of the following topics.

Pathway information

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Supporting information

Erythema migrans

Erythema migrans is an expanding rash often seen in the early stage of Lyme disease, and can also (but less commonly) be caused by southern tick-associated rash illness. It usually becomes visible from 1 to 4 weeks (but can appear from 3 days to 3 months) after a tick bite and lasts for several weeks.

Insect bite or sting

For the purpose of this NICE Pathway, 'insect bites' also includes bites from spiders and ticks. Insects may bite with their mouthparts when feeding or defending themselves. Stings come from bees, wasps and hornets and are used only for defence.

Antibiotics for prophylaxis and treatment in adults aged 18 years and over

Prophylaxis and treatment
Antibiotic, dosage and course length for prophylaxis (3 days) and treatment (5 days)
First-choice oral antibiotic
Co-amoxiclav:
250/125 mg or 500/125 mg three times a day
Alternative first-choice oral antibiotics for penicillin allergy or if co-amoxiclav is unsuitable
Doxycycline:
200 mg on first day, then 100 mg or 200 mg daily
with
Metronidazole:
400 mg three times a day
Alternative first-choice oral antibiotics in pregnancy for penicillin allergy or if co-amoxiclav is unsuitable
Seek specialist advice
First-choice intravenous antibiotic (if unable to take oral antibiotics or severely unwell)
Co-amoxiclav:
1.2 g three times a day
Alternative first-choice intravenous antibiotics for penicillin allergy or if co-amoxiclav is unsuitable
Cefuroxime (caution in penicillin allergy):
750 mg three times a day (increased to 750 mg four times a day or 1.5 g three or four times a day if infection is severe)
with
Metronidazole:
500 mg three times a day
Ceftriaxone (caution in penicillin allergy)
2 g once a day
with
Metronidazole:
500 mg three times a day
If cephalosporin is not appropriate
Seek specialist advice
See the BNF and summary of product characteristics for appropriate use and dosing in specific populations, for example, for people with hepatic or renal impairment, in pregnancy and breastfeeding, and when administering intravenous (or, if appropriate, intramuscular) antibiotics.
A 5-day course is appropriate for treating most human or animal bites, but course length can be increased to 7 days (with review) based on clinical assessment of the wound, for example, if there is significant tissue destruction or it has penetrated bone, joint, tendon or vascular structures.

Antibiotics for prophylaxis and treatment in children and young people under 18 years

Prophylaxis and treatment
Antibiotic, dosage and course length for prophylaxis (3 days) and treatment (5 days)
Choice for children under 1 month
Seek specialist advice
First-choice oral antibiotic for children aged 1 month and over
Co-amoxiclav:
1 month to 11 months: 0.25 ml/kg of 125/31 suspension three times a day
1 year to 5 years: 0.25 ml/kg or 5 ml of 125/31 suspension three times a day
6 years to 11 years: 0.15 ml/kg or 5 ml of 250/62 suspension three times a day
12 years to 17 years: 250/125 mg or 500/125 mg three times a day
Co-amoxiclav 400/57 suspension may also be considered to allow for twice-daily dosing
Alternative first-choice oral antibiotic for children under 12 years for penicillin allergy or if co-amoxiclav is unsuitable
Co-trimoxazole (off-label use):
6 weeks to 5 months: 120 mg or 24 mg/kg twice a day
6 months to 5 years: 240 mg or 24 mg/kg twice a day
6 years to 11 years: 480 mg or 24 mg/kg twice a day
See the BNF for Children for information on monitoring
Alternative first-choice oral antibiotics for young people aged 12 to 17 years for penicillin allergy or if co-amoxiclav is unsuitable
Doxycycline:
200 mg on first day, then 100 mg or 200 mg daily
with
Metronidazole:
400 mg three times a day
Alternative first-choice oral antibiotics in pregnancy for penicillin allergy or if co-amoxiclav unsuitable
Seek specialist advice
First-choice intravenous antibiotic (if unable to take oral antibiotics or severely ill)
Co-amoxiclav:
1 month to 2 months: 30 mg/kg twice a day
3 months to 17 years: 30 mg/kg three times a day (maximum per dose 1.2g)
Alternative first-choice intravenous antibiotics for penicillin allergy or if co-amoxiclav is unsuitable
Cefuroxime (caution in penicillin allergy):
1 month to 17 years: 20 mg/kg three times a day (maximum 750 mg per dose), which can be increased to 50 mg/kg to 60 mg/kg three or four times a day (maximum per dose 1.5 g)
with
Metronidazole:
1 month: loading dose 15 mg/kg, then (after 8 hours) 7.5 mg/kg three times a day
2 months to 17 years: 7.5 mg/kg three times a day (maximum per dose 500 mg)
Ceftriaxone (caution in penicillin allergy):
1 month to 11 years (up to 50 kg): 50 mg/kg to 80 mg/kg once a day (maximum 4 g per day)
9 years to 11 years (50 kg and above) and 12 years to 17 years: 1 g to 2 g once a day
with
Metronidazole:
1 month: loading dose 15 mg/kg, then (after 8 hours) 7.5 mg/kg three times a day
2 months to 17 years: 7.5 mg/kg three times a day (maximum per dose 500 mg)
If a cephalosporin is not appropriate
Seek specialist advice
See the BNF for Children and summary of product characteristics for appropriate use and dosing in specific populations, for example, for people with hepatic or renal impairment, in pregnancy and breastfeeding, and when administering intravenous (or, if appropriate, intramuscular) antibiotics.
A 5-day course is appropriate for treating most human or animal bites, but course length can be increased to 7 days (with review) based on clinical assessment of the wound, for example, if there is significant tissue destruction or it has penetrated bone, joint, tendon or vascular structures.
For off-label use, the prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's good practice in prescribing and managing medicines and devices for further information.

Glossary

Paths in this pathway

Pathway created: September 2020 Last updated: November 2020

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