This is a new guideline from NICE giving advice on antibiotic prescribing in leg ulcers, published in February 20.
As is the case with these antibiotic guidelines, there is an excellent visual summary.
What suggests that an ulcer is infected?
Many ulcers are colonised by bacteria, but are not infected. There is a useful definition of what an 'infected' ulcer looks like. The following may be signs of infection:
- redness or swelling beyond the edge of the ulcer.
- localised warmth.
- increased pain.
When should we swab?
- We should not swab at initial presentation, even if the ulcer looks infected.
- Consider sending a swab if the symptoms or signs are worsening or if the patient is not improving as expected. The ulcer should be cleaned first.
What antibiotics should we use?
Flucloxacillin is still first line. It can be used at doses of up to 1g QDS. This is off-label. The reason for suggesting a higher dose is because people with ulcers often have poor circulation and therefore lower bio-availability.
See the visual guide for alternatives if needed, but they are what you would expect.
How long should the course of antibiotics be?
Antibiotics should still be prescribed for 7 days. This is based on expert opinion as there isn't much research on this area.
It is worth noting that an ulcer will often still look infected even at the end of the 7d, but it doesn't necessarily mean that the patient needs a further course of antibiotics. Full resolution is not expected until after the end of the antibiotic course.
They do say that longer courses may be considered if the ulcer does not seem to be improving, especially if the patient is at risk of poor healing or has comorbidities that puts them at higher risk of complications.