Recommendations

Guidance

1.1 Managing secondary bacterial infections of eczema
1.2 Choice of antibiotic
1.3 Managing secondary bacterial infections of psoriasis, chicken pox, shingles and scabies

Recommendations

1.1 Managing secondary bacterial infections of eczema

Treatment

1.1.1 In people with symptoms or signs of cellulitis, follow the NICE guideline on cellulitis and erysipelas: antimicrobial prescribing.

1.1.2 Manage underlying eczema and flares with treatments such as emollients and topical corticosteroids, whether antibiotics are offered or not (see the NICE guideline on atopic eczema in under 12s and also see NICE's technology appraisal guidance on alitretinoin for the treatment of severe chronic hand eczema, dupilumab for treating moderate to severe atopic dermatitis, tacrolimus and pimecrolimus for atopic eczema and frequency of application of topical corticosteroids for atopic eczema).

1.1.3 Be aware that:

the symptoms and signs of secondary bacterial infection of eczema can include: weeping, pustules, crusts, no response to treatment, rapidly worsening eczema, fever and malaise
not all eczema flares are caused by a bacterial infection, so will not respond to antibiotics, even if weeping and crusts are present
eczema is often colonised with bacteria but may not be clinically infected
eczema can also be infected with herpes simplex virus (eczema herpeticum).

For managing eczema and eczema herpeticum in children under 12, see the NICE guideline on atopic eczema in under 12s.

1.1.4 Do not routinely take a skin swab for microbiological testing in people with secondary bacterial infection of eczema at the initial presentation.

1.1.5 In people who are not systemically unwell, do not routinely offer either a topical or oral antibiotic for secondary bacterial infection of eczema. Take into account:

the evidence, which suggests a limited benefit with antibiotics in addition to topical corticosteroids compared with topical corticosteroids alone
the risk of antimicrobial resistance with repeated courses of antibiotics
the extent and severity of symptoms or signs
the risk of developing complications, which is higher in people with underlying conditions such as immunosuppression.

1.1.6 If an antibiotic is offered to people who are not systemically unwell with a secondary bacterial infection of eczema (see the recommendations on choice of antibiotic), when choosing between a topical or oral antibiotic, take into account:

their preferences (and those of their parents and carers as appropriate) for topical or oral administration
the extent and severity of symptoms or signs (a topical antibiotic may be more appropriate if the infection is localised and not severe; an oral antibiotic may be more appropriate if the infection is widespread or severe)
possible adverse effects
previous use of topical antibiotics because antimicrobial resistance can develop rapidly with extended or repeated use.

1.1.7 In people who are systemically unwell, offer an oral antibiotic for secondary bacterial infection of eczema (see the recommendations on choice of antibiotic).

For a short explanation of why the committee made these recommendations, see the rationale section on treatment.

For more details, see the evidence review.

Advice

1.1.8 If an antibiotic is not given, advise the person (and their parents and carers as appropriate):

about the reasons why an antibiotic is unlikely to provide any benefit
to seek medical help if symptoms worsen rapidly or significantly at any time.

1.1.9 If an antibiotic is given, advise the person (and their parents and carers as appropriate):

about possible adverse effects
about the risk of developing antimicrobial resistance with extended or repeated use
that they should continue treatments such as emollients and topical corticosteroids
that it can take time for secondary bacterial infection of eczema to resolve, and full resolution is not expected until after the antibiotic course is completed
to seek medical help if symptoms worsen rapidly or significantly at any time.

For a short explanation of why the committee made these recommendations, see the rationale section on advice.

For more details, see the evidence review.

Reassessment

1.1.10 Reassess people with secondary bacterial infection of eczema if:

they become systemically unwell or have pain that is out of proportion to the infection
their symptoms worsen rapidly or significantly at any time
their symptoms have not improved after completing a course of antibiotics.

1.1.11 When reassessing people with secondary bacterial infection of eczema, take account of:

other possible diagnoses, such as eczema herpeticum
any symptoms or signs suggesting a more serious illness or condition, such as cellulitis, necrotising fasciitis or sepsis
previous antibiotic use, which may have caused resistant bacteria.

1.1.12 For people with secondary bacterial infection of eczema that is worsening or has not improved as expected, consider sending a skin swab for microbiological testing.

1.1.13 For people with secondary bacterial infection of eczema that recurs frequently:

send a skin swab for microbiological testing and
consider taking a nasal swab and starting treatment for decolonisation.

1.1.14 If a skin swab has been sent for microbiological testing:

review the choice of antibiotic when results are available and
change the antibiotic according to results if symptoms are not improving, using a narrow‑spectrum antibiotic if possible.

For a short explanation of why the committee made these recommendations, see the rationale section on reassessment.

For more details, see the evidence review.

Referral and seeking specialist advice

1.1.15 Refer people with secondary bacterial infection of eczema to hospital if they have any symptoms or signs suggesting a more serious illness or condition, such as necrotising fasciitis or sepsis.

1.1.16 Consider referral or seeking specialist advice for people with secondary bacterial infection of eczema if they:

have spreading infection that is not responding to oral antibiotics
are systemically unwell
are at high risk of complications
have infections that recur frequently.

For a short explanation of why the committee made these recommendations, see the rationale section on referral and seeking specialist advice.

For more details, see the evidence review.

1.2 Choice of antibiotic

1.2.1 When prescribing an antibiotic for secondary bacterial infection of eczema, take account of local antimicrobial resistance data when available and follow:

table 1 for adults aged 18 years and over
table 2 for children and young people under 18 years (for children under 1 month, antibiotic choice is based on specialist advice).

**Table 1 Choice of antibiotics for adults aged 18 years and over**
Treatment	Antibiotic, dosage and course length
For secondary bacterial infection of eczema in people who are not systemically unwell	Do not routinely offer either a topical or oral antibiotic
First-choice topical if a topical antibiotic is appropriate (see recommendations 1.1.5 and 1.1.6)	Fusidic acid 2%: Apply three times a day for 5 to 7 days For localised infections only. Extended or recurrent use may increase the risk of developing antimicrobial resistance.
First-choice oral if an oral antibiotic is appropriate (see recommendations 1.1.5 to 1.1.7)	Flucloxacillin: 500 mg four times a day for 5 to 7 days
Alternative oral antibiotic for penicillin allergy or if flucloxacillin is unsuitable (for people who are not pregnant)	Clarithromycin: 250 mg twice a day for 5 to 7 days The dosage can be increased to 500 mg twice a day for severe infections.
Alternative oral antibiotic for penicillin allergy in pregnancy	Erythromycin: 250 mg to 500 mg four times a day for 5 to 7 days Erythromycin is preferred if a macrolide is needed in pregnancy, for example, if there is true penicillin allergy and the benefits of antibiotic treatment outweigh the harms. See the Medicines and Healthcare products Regulatory Agency (MHRA) Public Assessment Report on the safety of macrolide antibiotics in pregnancy.
If meticillin-resistant *Staphylococcus aureus* is suspected or confirmed	Consult a microbiologist

See the BNF for appropriate use and dosing of the antibiotics recommended in specific populations, for example, people with hepatic or renal impairment, and in pregnancy and breastfeeding.

**Table 2 Choice of antibiotics for children and young people aged from 1 month to under 18 years**
Treatment	Antibiotic, dosage and course length
For secondary bacterial infection of eczema in people who are not systemically unwell	Do not routinely offer either a topical or oral antibiotic
First-choice topical if a topical antibiotic is appropriate (see recommendations 1.1.5 and 1.1.6)	Fusidic acid 2%: Apply three times a day for 5 to 7 days For localised infections only. Extended or recurrent use may increase the risk of developing antimicrobial resistance.
First-choice oral if an oral antibiotic is appropriate (see recommendations 1.1.5 to 1.1.7)	Flucloxacillin (oral solution or capsules): 1 month to 1 year: 62.5 mg to 125 mg four times a day for 5 to 7 days 2 years to 9 years: 125 mg to 250 mg four times a day for 5 to 7 days 10 years to 17 years: 250 mg to 500 mg four times a day for 5 to 7 days
Alternative oral antibiotic for penicillin allergy or if flucloxacillin is unsuitable (for people who are not pregnant)	Clarithromycin: 1 month to 11 years: under 8 kg: 7.5 mg/kg twice a day for 5 to 7 days 8 kg to 11 kg: 62.5 mg twice a day for 5 to 7 days 12 kg to 19 kg: 125 mg twice a day for 5 to 7 days 20 kg to 29 kg: 187.5 mg twice a day for 5 to 7 days 30 kg to 40 kg: 250 mg twice a day for 5 to 7 days 12 years to 17 years: 250 mg twice a day for 5 to 7 days. The dosage can be increased to 500 mg twice a day for severe infections
Alternative oral antibiotic for penicillin allergy in pregnancy	Erythromycin: 8 years to 17 years: 250 mg to 500 mg four times a day for 5 to 7 days Erythromycin is preferred if a macrolide is needed in pregnancy, for example, if there is true penicillin allergy and the benefits of antibiotic treatment outweigh the harms. See the Medicines and Healthcare products Regulatory Agency (MHRA) Public Assessment Report on the safety of macrolide antibiotics in pregnancy.
If meticillin-resistant *Staphylococcus aureus* is suspected or confirmed	Consult a local microbiologist

See the BNF for Children for appropriate use and dosing of the antibiotics recommended in specific populations, for example, people with hepatic or renal impairment, and in pregnancy and breastfeeding.

The age bands for children apply to children of average size. In practice, they will be used alongside other factors such as the severity of the condition being treated and the child's size in relation to the average size of children of the same age.

For advice on helping children to swallow medicines, see Medicines for Children's leaflet on helping your child to swallow tablets.

For a short explanation of why the committee made these recommendations, see the rationale section on choice of antibiotic.

For more details, see the summary of the evidence.

1.3 Managing secondary bacterial infections of psoriasis, chicken pox, shingles and scabies

Treatment

1.3.1 Be aware that no evidence was found on the use of antibiotics in managing secondary bacterial infections of other common skin conditions such as psoriasis, chicken pox, shingles and scabies. Seek specialist advice, if needed.

For a short explanation of why the committee made this recommendation, see the rationale section on treatment.

For more details, see the evidence review.