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Leg ulcers

About

What is covered

This NICE Pathway covers antimicrobial prescribing for adults with leg ulcer infection and wound management for leg ulcers. 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 leg ulcers in an interactive flowchart

What is covered

This NICE Pathway covers antimicrobial prescribing for adults with leg ulcer infection and wound management for leg ulcers. It aims to optimise antibiotic use and reduce antibiotic resistance.

Sources

NICE guidance and other sources used to create this interactive flowchart.
UrgoStart for treating diabetic foot ulcers and leg ulcers (2019) NICE medical technologies guidance 42
Prontosan for acute and chronic wounds (2020) NICE medtech innovation briefing 220
Coban 2 for venous leg ulcers (2018) NICE medtech innovation briefing 140

Quality standards

Quality statements

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

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

This is a rare but serious bacterial infection that affects the tissue beneath the skin and surrounding muscles and organs (fascia). Early symptoms can include intense pain that is out of proportion to any damage to the skin, and fever. The most common cause is group A Streptococcus.
This is an infection of the bone. It can be very painful and most commonly occurs in the long bones of the leg. It can also occur in other bones, such as those in the back or arms. Anyone can develop osteomyelitis, but certain people are more at risk, including people with diabetes and those with a weakened immune system.

Antibiotics for adults aged 18 years and over with an infected leg ulcer

When prescribing antibiotics for an infected leg ulcer in adults aged 18 years and over, follow the recommendations below.
Antibiotic
Dosage and course length
First-choice oral antibiotic
Flucloxacillin
500 mg to 1 g four times a day for 7 days (In February 2020, 1 g four times a day was off label. See prescribing medicines at NICE website.)
Alternative first-choice oral antibiotics for penicillin allergy or if flucloxacillin unsuitable
Doxycycline
200 mg on first day, then 100 mg once a day (can be increased to 200 mg daily) for 7 days in total
Clarithromycin
500 mg twice a day for 7 days
Erythromycin (in pregnancy)
500 mg four times a day for 7 days
Second-choice oral antibiotics (guided by microbiological results when available)
Co-amoxiclav
500/125 mg three times a day for 7 days
Co-trimoxazole (in penicillin allergy)
960 mg twice a day for 7 days (In February 2020, co-trimoxazole was off label for leg ulcer infection. See prescribing medicines at NICE website. See the BNF for information on monitoring.)
First-choice antibiotics if severely unwell (guided by microbiological results if available)
Flucloxacillin with or without
1 g to 2 g four times a day intravenously
Gentamicin and/or
Initially, 5 mg/kg to 7 mg/kg once daily intravenously, subsequent doses if needed according to serum gentamicin concentration (see the BNF for information on monitoring)
Metronidazole
400 mg three times a day orally or 500 mg three times a day intravenously
Co-amoxiclav with or without
1.2 g three times a day intravenously
Gentamicin
Initially 5 mg/kg to 7 mg/kg once daily intravenously, subsequent doses if needed according to serum gentamicin concentration (see the BNF for information on monitoring)
Co-trimoxazole (in penicillin allergy) with or without
960 mg twice a day intravenously (increased to 1.44 g twice a day if severe infection) (In February 2020, co-trimoxazole was off label for leg ulcer infection. See prescribing medicines at NICE website. See the BNF for information on monitoring.)
Gentamicin and/or
Initially 5 mg/kg to 7 mg/kg once daily intravenously, subsequent doses if needed according to serum gentamicin concentration (see the BNF for information on monitoring)
Metronidazole
400 mg three times a day orally or 500 mg three times a day intravenously
Second-choice antibiotics if severely unwell (guided by microbiological results when available or following specialist advice)
Piperacillin with tazobactam
4.5 g three times a day intravenously (increased to 4.5 g four times a day if severe infection)
Ceftriaxone with or without
2 g once a day intravenously
Metronidazole
400 mg three times a day orally or 500 mg three times a day intravenously
Antibiotics to be added if MRSA infection is suspected or confirmed (combination therapy with antibiotics listed above)
Vancomycin
15 mg/kg to 20 mg/kg two or three times a day intravenously (maximum 2 g per dose), adjusted according to serum vancomycin concentration (see the BNF for information on monitoring)
Teicoplanin
Initially 6 mg/kg every 12 hours for three doses, then 6 mg/kg once a day intravenously (see the BNF for information on monitoring)
Linezolid (if vancomycin or teicoplanin cannot be used; specialist advice only)
600 mg twice a day orally or intravenously (see the BNF for information on monitoring)
See the BNF for appropriate use and dosing in specific populations, for example, people with hepatic or renal impairment, in pregnancy and breastfeeding, and when administering intravenous (or, where appropriate, intramuscular) antibiotics.
Review intravenous antibiotics by 48 hours and consider switching to oral antibiotics if possible.
See the NICE guideline to find out why we made these recommendations.

Glossary

(intravenous)
(a long-lasting [chronic] open wound that takes more than 4 to 6 weeks to heal; they usually develop on the lower leg, between the shin and the ankle)
(long-lasting [chronic] open wounds that take more than 4 to 6 weeks to heal; they usually develop on the lower leg, between the shin and the ankle)
(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: February 2020 Last updated: November 2020

© NICE 2020. All rights reserved. Subject to Notice of rights.

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