Eczema - Management of Infection Guidance for Primary Care

Publication: 30/09/2010  
Next review: 21/10/2023  
Clinical Guideline
ID: 2255 
Approved By: LAPC 
Copyright© Leeds Teaching Hospitals NHS Trust 2020  


This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.





If no visible signs of infection, use of antibiotics (alone or with steroids) encourages resistance and does not improve healing 1B
In eczema with visible signs of infection, use treatment as in impetigo 2C

Principles of Treatment

  1. This guidance is based on the best available evidence but its application must be modified by professional judgement.
  2. . Inappropriate specimens (e.g. routine ulcer swab or routine catheter specimen of urine) lead to inappropriate antibiotic prescribing.
  3. Prescribe an antibiotic only when there is likely to be a clear clinical benefit.
  4. Limit prescribing over the telephone to exceptional cases.
  5. Use simple generic antibiotics if possible. Avoid broad spectrum antibiotics (e.g. Co-Amoxiclav (Amoxicillin-Clavulanate), quinolones and cephalosporins) when narrow spectrum antibiotics remain effective, as they increase risk of Clostridium difficile, MRSA and resistant UTI's.
  6. Avoid widespread use of topical antibiotics (especially those agents also available as systemic preparations).
  7. In pregnancy AVOID tetracyclines, aminoglycosides, quinolones, and high dose metronidazole. Short-term use of trimethoprim (unless low folate status or taking another folate antagonist such as antiepileptic or proguanil) or nitrofurantoin (at term, theoretical risk of neonatal haemolysis) is unlikely to cause problems to the foetus.
  8. We recommend clarithromycin as it has less side-effects than erythromycin, greater compliance as twice rather than four times daily & generic tablets are similar cost. In children erythromycin may be preferable as clarithromycin syrup is twice the cost.
  9. Where a ‘best guess’ therapy has failed or special circumstances exist, microbiological advice can be obtained from LTHT Microbiology (Mon-Fri 9am-5pm and Sat and Sun 9am-1pm: 0113 39 23962/28580; Otherwise via LTHT switchboard - ask for the On call Microbiology Registrar)


Record: 2255
  • to provide a simple, empirical approach to the treatment of common infections
  • to promote the safe, effective and economic use of antibiotics
  • to minimise the emergence of bacterial resistance and reduce the incidence of Healthcare Associated Infections in the community
Clinical condition:


Target patient group:
Target professional group(s): Primary Care Doctors
Adapted from:

This guidance was initially developed in 1999 by practitioners in South Devon, as part of the S&W Devon Joint Formulary Initiative, and Cheltenham & Tewkesbury Prescribing Group and modified by the PHLS South West Antibiotic Guidelines Project Team, PHLS Primary Care Co-ordinators and members of the Clinical Prescribing Sub-group of the Standing Medical Advisory Committee on Antibiotic Resistance. It was further modified following comments from Internet users. The guidance has been updated annually as significant research papers, systematic reviews and guidance have been published. The Health Protection Agency works closely with the authors of the Clinical Knowledge Summaries.

Evidence base

Grading of guidance recommendations
The strength of each recommendation is qualified by a letter in parenthesis.

Study design


Good recent systematic review of studies


One or more rigorous studies, not combined


One or more prospective studies


One or more retrospective studies


Formal combination of expert opinion


Informal opinion, other information


Letters indicate strength of evidence:
A+ = systematic review: D = informal opinion

  1. Birnie AJ, Bath-Hextall FJ, Ravenscroft JC, Williams HC. Interventions to reduce Staphylococcus aureus in the management of atopic eczema. Cochrane Database of Systematic Reviews. 2008. Issue 3. Accessed 23.09.14. RATIONALE: Most RCTs identified by this Cochrane review were of small, of poor quality and heterogeneous. Oral antibiotics were not associated with benefit in two small trials of people with eczema without visible signs of infection (n=66). Adding antibiotics to topical steroids reduced the numbers of S aureus in 4 trials (n=302) but not in a further 9 trials (n=677).
  2.  National Collaborating Centre for Women's and Children's Health (2007) Atopic eczema in children: management of atopic eczema in children from birth up to the age of 12 years (full NICE guideline). National Institute for Health and Clinical Excellence. Accessed 23.09.14. RATIONALE: In view of the lack of robust trial evidence, the Guidance Development Group’s view was that flucloxacillin should normally be the first-line treatment for active S. aureus and streptococcal infection because it is active against both. If sensitive, erythromycin or clarithromycin should be used when there is local resistance to flucloxacillin and in children with a penicillin allergy because it is as effective as cephalosporins and less costly. It is the view of the GDG that topical antibiotics, including those combined with topical corticosteroids, should be used to treat localised overt infection only, and for no longer than two weeks.

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Document history

LHP version 1.0

Related information

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