A-Z
Topics
Latest

Cellulitis and erysipelas – antimicrobial prescribing

About

What is covered

This NICE Pathway covers antimicrobial prescribing for adults, young people, children and babies aged 72 hours and over with cellulitis and erysipelas. It aims to optimise antibiotic use and reduce antibiotic resistance.

Updates

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 cellulitis and erysipelas in an interactive flowchart

What is covered

This NICE Pathway covers antimicrobial prescribing for adults, young people, children and babies aged 72 hours and over with cellulitis and erysipelas. It aims to optimise antibiotic use and reduce antibiotic resistance.

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

Infections of the tissues under the skin (subcutaneous), which usually result from contamination of a break in the skin. Both conditions are characterised by acute localised inflammation and oedema, with lesions more superficial in erysipelas with a well-defined, raised margin (World Health Organization 2018).
Infections of the tissues under the skin (subcutaneous), which usually result from contamination of a break in the skin. Both conditions are characterised by acute localised inflammation and oedema, with lesions more superficial in erysipelas with a well-defined, raised margin (World Health Organization 2018).

Antibiotics for children and young people under 18 years

Antibiotic1
Dosage and course length2
Children under 1 month
Antibiotic choice based on specialist advice
Children aged 1 month and over
First-choice antibiotic (give oral unless person unable to take oral or severely unwell)3
Flucloxacillin4
1 month to 1 year, 62.5 mg to 125 mg four times a day orally for 5 to 7 days5
2 to 9 years, 125 mg to 250 mg four times a day orally for 5 to 7 days5
10 to 17 years, 250 mg to 500 mg four times a day orally for 5 to 7 days5
or 1 month to 17 years, 12.5 mg to 25 mg/kg four times a day IV (maximum 1 g four times a day)6
Alternative first-choice antibiotics for penicillin allergy or if flucloxacillin unsuitable (give oral unless person unable to take oral or severely unwell)3
Co-amoxiclav (not in penicillin allergy)7
1 to 11 months, 0.25 ml/kg of 125/31 suspension three times a day orally for 5 to 7 days5 (dose doubled in severe infection)
1 to 5 years, 0.25 ml/kg or 5 ml of 125/31 suspension three times a day orally for 5 to 7 days5 (dose doubled in severe infection)
6 to 11 years, 0.15 ml/kg or 5 ml of 250/62 suspension three times a day orally for 5 to 7 days5 (dose doubled in severe infection)
12 to 17 years, 250/125 mg or 500/125 mg three times a day orally for 5 to 7 days5
or 1 to 2 months, 30 mg/kg twice a day IV6
3 months to 17 years, 30 mg/kg three times a day IV (maximum 1.2 g three times a day)6
Clarithromycin
1 month to 11 years:
Under 8 kg, 7.5 mg/kg twice a day orally for 5 to 7 days5
8 to 11 kg, 62.5 mg twice a day orally for 5 to 7 days5
12 to 19 kg, 125 mg twice a day orally for 5 to 7 days5
20 to 29 kg, 187.5 mg twice a day orally for 5 to 7 days5
30 to 40 kg, 250 mg twice a day orally for 5 to 7 days5
12 to 17 years:
250 to 500 mg twice a day orally for 5 to 7 days5
or 1 month to 11 years, 7.5 mg/kg twice a day IV (maximum 500 mg per dose)6
12 to 17 years, 500 mg twice a day IV6
Erythromycin (in pregnancy)
8 to 17 years, 250 to 500 mg four times a day orally for 5 to 7 days5
First-choice antibiotic if infection near the eyes or nose8 (consider seeking specialist advice; give oral unless person unable to take oral or severely unwell)3
Co-amoxiclav7
1 to 11 months, 0.25 ml/kg of 125/31 suspension three times a day orally for 7 days5 (dose can be doubled in severe infection)
1 to 5 years, 0.25 ml/kg or 5 ml of 125/31 suspension three times a day orally for 7 days5 (dose can be doubled in severe infection)
6 to 11 years, 0.15 ml/kg or 5 ml of 250/62 suspension three times a day orally for 7 days5 (dose can be doubled in severe infection)
12 to 17 years, 250/125 mg or 500/125 mg three times a day orally for 7 days5
or 1 to 2 months, 30 mg/kg twice a day IV6
3 months to 17 years, 30 mg/kg three times a day IV (maximum 1.2 g three times a day)6
Alternative first-choice antibiotics if infection near the eyes or nose8 for penicillin allergy or if co-amoxiclav unsuitable (consider seeking specialist advice; give oral unless person unable to take oral or severely unwell)3
Clarithromycin
1 month to 11 years:
Under 8 kg, 7.5 mg/kg twice a day orally for 7 days5
8 to 11 kg, 62.5 mg twice a day orally for 7 days5
12 to 19 kg, 125 mg twice a day orally for 7 days5
20 to 29 kg, 187.5 mg twice a day orally for 7 days5
30 to 40 kg, 250 mg twice a day orally for 7 days5
12 to 17 years:
250 to 500 mg twice a day orally for 7 days5
or 1 month to 11 years, 7.5 mg/kg twice a day IV (maximum 500 mg per dose)6
12 to 17 years, 500 mg twice a day IV6
with (if anaerobes suspected):
Metronidazole
1 month, 7.5 mg/kg twice a day orally for 7 days5
2 months to 11 years, 7.5 mg/kg three times a day orally (maximum per dose 400 mg) for 7 days5
12 to 17 years, 400 mg three times a day for 7 days5
or 1 month, loading dose 15 mg/kg, then (after 8 hours) 7.5 mg/kg three times a day IV6
2 months to 17 years, 7.5 mg/kg three times a day IV (maximum per dose 500 mg)6
Alternative choice antibiotics for severe infection9
Co-amoxiclav7
1 to 11 months, 0.25 ml/kg of 125/31 suspension three times a day orally for 7 days5 (dose can be doubled)
1 to 5 years, 0.25 ml/kg or 5 ml of 125/31 suspension three times a day orally for 7 days5 (dose can be doubled)
6 to 11 years, 0.15 ml/kg or 5 ml of 250/62 suspension three times a day orally for 7 days5 (dose can be doubled)
12 to 17 years, 250/125 mg or 500/125 mg three times a day orally for 7 days5
or 1 to 2 months, 30 mg/kg twice a day IV6
3 months to 17 years, 30 mg/kg three times a day IV (maximum 1.2 g three times a day)6
Cefuroxime
1 month to 17 years, 20 mg/kg three times a day IV (maximum 750 mg per dose), can be increased to 50 to 60 mg/kg three or four times a day IV (maximum 1.5 g per dose)6
Clindamycin
1 month to 17 years, 3 to 6 mg/kg four times a day orally (maximum per dose 450 mg) for 7 days5
or 1 month to 17 years, 3.75 to 6.25 mg/kg four times a day IV, increased if necessary, in life-threatening infection to 10 mg/kg four times a day IV (maximum per dose 1.2 g); total daily dose may alternatively be given in three divided doses (maximum per dose 1.2 g)6
Antibiotics to be added if suspected or confirmed MRSA infection (combination therapy with an antibiotic listed above)9
Vancomycin10,11
1 month to 11 years, 10 to 15 mg/kg four times a day IV, adjusted according to serum vancomycin concentration6
12 to 17 years, 15 to 20 mg/kg two or three times a day IV (maximum 2 g per dose), adjusted according to serum vancomycin concentration6
Teicoplanin10,11
1 month, initially 16 mg/kg for one dose, then (after 24 hours) 8 mg/kg once a day IV6
2 months to 11 years, initially 10 mg/kg every 12 hours for 3 doses, then 6 to 10 mg/kg once a day IV6
12 to 17 years, initially 6 mg/kg every 12 hours for three doses, then 6 mg/kg once a day IV6
Linezolid (if vancomycin or teicoplanin cannot be used; specialist use only)11,12
1 month to 11 years, 10 mg/kg three times a day orally (maximum 600 mg per dose)
12 to 17 years, 600 mg twice a day orally
or 1 month to 11 years, 10 mg/kg three times a day IV (maximum 600 mg per dose)6
12 to 17 years, 600 mg twice a day IV6
1 See BNF for children for appropriate use and dosing in specific populations, for example, hepatic impairment, renal impairment, pregnancy and breastfeeding, and administering intravenous (or, where appropriate, intramuscular) antibiotics.
2 The age bands apply to children of average size and, in practice, the prescriber will use the age bands in conjunction with other factors such as the severity of the condition and the child's size in relation to the average size of children of the same age. Oral doses are for immediate-release medicines.
3 Give oral antibiotics first line if the child or young person can take oral medicines, and the severity of their symptoms does not require intravenous antibiotics.
4 If flucloxacillin oral solution is not tolerated because of poor palatability, consider capsules (see Medicines for Children leaflet on helping your child to swallow tablets).
5 A longer course (up to 14 days in total) may be needed based on clinical assessment. However, skin does take some time to return to normal, and full resolution of symptoms at 5 to 7 days is not expected.
6 If intravenous antibiotics are given, review by 48 hours and consider switching to oral antibiotics if possible for the appropriate course length.
7 Co-amoxiclav 400/57 suspension may also be considered to allow twice daily dosing (see BNF for children for dosing information).
8 Infection around the eyes or the nose (the triangle from the bridge of the nose to the corners of the mouth, or immediately around the eyes including periorbital cellulitis) is of more concern because of risk of a serious intracranial infection.
9 Other antibiotics may be appropriate based on microbiological results and specialist advice.
10 See BNF for children for information on therapeutic drug monitoring.
11 See BNF for children for information on monitoring of patient parameters.
12 Not licensed in children and young people under 18 years, so use would be off label. 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.

Antibiotics for adults aged 18 years and over

Antibiotic1
Dosage and course length2
First-choice antibiotic (give oral unless person unable to take oral or severely unwell)3
Flucloxacillin
500 mg to 1 g four times a day orally4 for 5 to 7 days5
or 1 to 2 g four times a day IV6
Alternative first-choice antibiotics for penicillin allergy or if flucloxacillin unsuitable (give oral unless person unable to take oral or severely unwell)3
Clarithromycin
500 mg twice a day orally for 5 to 7 days5
or 500 mg twice a day IV6
Erythromycin (in pregnancy)
500 mg four times a day orally for 5 to 7 days5
Doxycycline
200 mg on first day, then 100 mg once a day orally for 5 to 7 days in total5
First-choice antibiotic if infection near the eyes or nose7 (consider seeking specialist advice; give oral unless person unable to take oral or severely unwell)3
Co-amoxiclav
500/125 mg three times a day orally for 7 days5
or 1.2 g three times a day IV6
Alternative first-choice antibiotics if infection near the eyes or nose7 for penicillin allergy or if co-amoxiclav unsuitable (consider seeking specialist advice; give oral unless person unable to take oral or severely unwell)3
Clarithromycin
500 mg twice a day orally for 7 days5
or 500 mg twice a day IV6
with metronidazole
400 mg three times a day orally for 7 days5
or 500 mg three times a day IV6
Alternative choice antibiotics for severe infection
Co-amoxiclav
500/125 mg three times a day orally for 7 days5
or 1.2 g three times a day IV6
Cefuroxime
750 mg to 1.5 g three or four times a day IV6
Clindamycin
150 to 300 mg four times a day (can be increased to 450 mg four times a day) orally for 7 days5
or 600 mg to 2.7 g daily IV in two to four divided doses, increased if necessary in life-threatening infection to 4.8 g daily (maximum per dose 1.2 g)6
Ceftriaxone (only for ambulatory care8)
2 g once a day IV6
Antibiotics to be added if MRSA infection is suspected or confirmed (combination therapy with an antibiotic listed above)8
Vancomycin9,10
15 to 20 mg/kg two or three times a day IV (maximum 2 g per dose), adjusted according to serum vancomycin concentration6
Teicoplanin9,10
Initially 6 mg/kg every 12 hours for three doses, then 6 mg/kg once a day IV6
Linezolid (if vancomycin or teicoplanin cannot be used; specialist use only)10
600 mg twice a day orally
or 600 mg twice a day IV6
1 See BNF for appropriate use and dosing in specific populations, for example, hepatic impairment, renal impairment, pregnancy and breastfeeding, and administering intravenous (or, where appropriate, intramuscular) antibiotics.
2 Oral doses are for immediate-release medicines.
3 Give oral antibiotics first line if the person can take oral medicines, and the severity of their symptoms does not require intravenous antibiotics.
4 The upper dose of 1 g four times a day would be off-label. 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.
5 A longer course (up to 14 days in total) may be needed based on clinical assessment. However, skin does take some time to return to normal, and full resolution of symptoms at 5 to 7 days is not expected.
6 If intravenous antibiotics are given, review by 48 hours and consider switching to oral antibiotics if possible for the appropriate course length.
7 Infection around the eyes or the nose (the triangle from the bridge of the nose to the corners of the mouth, or immediately around the eyes including periorbital cellulitis) is of more concern because of risk of a serious intracranial complication.
8 Other antibiotics may be appropriate based on microbiological results and specialist advice.
9 See BNF for information on therapeutic drug monitoring.
10 See BNF for information on monitoring of patient parameters.

Antibiotic prophylaxis for adults 18 years and over

Antibiotic prophylaxis1,2
Dosage3
First choice
Phenoxymethylpenicillin
250 mg twice a day
Alternative first choice for penicillin allergy
Erythromycin
250 mg twice a day
Consult local microbiologist for alternative antibiotics
1 See BNF for appropriate use and dosing in specific populations, for example, hepatic impairment, renal impairment, pregnancy and breastfeeding.
2 Choose antibiotics according to recent microbiological results where possible. Avoid using the same antibiotic for treatment and prophylaxis.
3 Doses given are by mouth using immediate release medicines, unless otherwise stated.

Glossary

(clinical care that may include diagnosis, observation, treatment and rehabilitation not provided within the traditional hospital bed base or within the traditional outpatient services that can be provided across primary/secondary care)
(intravenous)
(meticillin resistant Staphylococcus aureus)
(a medicine with an existing UK marketing authorisation that is used outside the terms of its marketing authorisation, for example, by indication, dose, route or patient population)

Paths in this pathway

Pathway created: September 2019 Last updated: September 2019

© NICE 2019. All rights reserved. Subject to Notice of rights.

Recently viewed