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[null,"Baseline assessment: Cellulitis and erysipelas: antimicrobial prescribing"]
[null,"NG141"]
[]
[]
[null,"Published: September 2019"]

{"sheet":"Introduction","index":1,"n_rows":23,"n_cols":2,"rows_kept":23,"cut":false,"hidden":false,"merged":[]}
[null,"Baseline assessment tool for cellulitis and erysipelas: (NICE antimicrobial prescribing guideline NG141)"]
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[null,"This baseline assessment tool can be used to evaluate whether practice is in line with the recommendations in Cellulitis and erysipelas: antimicrobial prescribing.  It can also help to plan activity to meet the recommendations."]
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[null,"The tool can be used by individual services or organisations. Alternatively, an assessment completed with the involvement of all relevant services or organisations would help to develop a picture of activity in the local area."]
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[null,"It should be used in conjunction with Cellulitis and erysipelas: (NICE antimicrobial prescribing guideline NG141)."]
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[null,"In the first instance, consider whether the guideline is relevant and record the conclusion in the box below."]
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[null,"Is the guideline relevant?"]
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[]
[null,"The data sheet contains the recommendations from the guideline. Information can be entered about current activity relevant to the recommendation, actions needed to meet the recommendation, deadlines and the names of the responsible leads.  Useful documents can be added as hyperlinks."]
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[null,"The table can be adapted to include any other local information that is thought to be useful."]
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[null,"If it would be helpful to group the recommendations, for example those that are key priorities for implementation or by deadline, use the filter function in the data menu. "]
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[null,"Tools and resources to help put the guidance into practice are available on the NICE website. "]
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[null,"National Institute for Health and Care Excellence\nLevel 1A, City Tower, Piccadilly Plaza, Manchester M1 4BT; www.nice.org.uk\n\nCopyright\n© NICE 2019. All rights reserved. Subject to Notice of rights.\n"]

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[null,"Baseline assessment tool for cellulitis and erysipelas: (NICE antimicrobial prescribing guideline NG141)"]
[]
[null,null,null,null,"Number of relevant recommendations",{"$f":"COUNTIF(D8:D995,\"Yes\")","v":0}]
[null,null,null,null,"Number of recommendations met",{"$f":"COUNTIF(F8:F995,\"Yes\")","v":0}]
[null,null,null,null,"Percentage of recommendations met",{"$f":"IF(ISERROR(F4/F3),\"\",F4/F3)","v":""}]
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[null,"NICE recommendation","Guideline reference","Is the recommendation relevant?","Current activity/evidence","Recommendation met?","Actions needed to implement recommendation","Is there a risk associated with not implementing this recommendation?","Is there a cost or saving?","Deadline","Lead"]
[null,"1.1  Managing cellulitis and erysipelas"]
[null,"Treatment"]
[null,"To ensure that cellulitis and erysipelas are treated appropriately, exclude other causes of skin redness such as:\n•\tan inflammatory reaction to an immunisation or an insect bite, or\n•\ta non-infectious cause such as chronic venous insufficiency. ","1.1.1"]
[null,"Consider taking a swab for microbiological testing from people with cellulitis or erysipelas to guide treatment, but only if the skin is broken and:\n•\tthere is a penetrating injury, or\n•\tthere has been exposure to water-borne organisms, or\n•\tthe infection was acquired outside the UK.","1.1.2"]
[null,"Before treating cellulitis or erysipelas, consider drawing around the extent of the infection with a single-use surgical marker pen to monitor progress. Be aware that redness may be less visible on darker skin tones.","1.1.3"]
[null,"Offer an antibiotic for people with cellulitis or erysipelas. When choosing an antibiotic (see the recommendations on choice of antibiotic) take account of: \n•\tthe severity of symptoms\n•\tthe site of infection (for example, near the eyes or nose)\n•\tthe risk of uncommon pathogens (for example, from a penetrating injury, after exposure to water-borne organisms, or an infection acquired outside the UK)\n•\tprevious microbiological results from a swab\n•\tthe person’s MRSA status if known. ","1.1.4"]
[null,"Give oral antibiotics first-line if the person can take oral medicines, and the severity of their condition does not require intravenous antibiotics.","1.1.5"]
[null,"If intravenous antibiotics are given, review by 48 hours and consider switching to oral antibiotics if possible.","1.1.6"]
[null,"Manage any underlying condition that may predispose to cellulitis or erysipelas, for example:\n•\tdiabetes\n•\tvenous insufficiency\n•\teczema\n•\toedema, which may be an adverse effect of medicines such as calcium channel blockers.","1.1.7"]
[null,"Advice"]
[null,"When prescribing antibiotics for cellulitis or erysipelas, give advice about:\n•\tpossible adverse effects of antibiotics \n•\tthe skin taking some time to return to normal after the course of antibiotics has finished\n•\tseeking medical help if symptoms worsen rapidly or significantly at any time, or do not start to improve within 2 to 3 days.","1.1.8"]
[null,"Reassessment"]
[null,"Reassess people with cellulitis or erysipelas if symptoms worsen rapidly or significantly at any time, do not start to improve within 2 to 3 days, or the person: \n•\tbecomes systemically very unwell, or\n•\thas severe pain out of proportion to the infection, or \n•\thas redness or swelling spreading beyond the initial presentation (taking into account that some initial spreading may occur, and that redness may be less visible on darker skin tones), see recommendation 1.1.3.","1.1.9"]
[null,"When reassessing people with cellulitis or erysipelas, take account of:\n•\tother possible diagnoses, such as an inflammatory reaction to an immunisation or an insect bite, gout, superficial thrombophlebitis, eczema, allergic dermatitis or deep vein thrombosis\n•\tany underlying condition that may predispose to cellulitis or erysipelas, such as oedema, diabetes, venous insufficiency or eczema\n•\tany symptoms or signs suggesting a more serious illness or condition, such as lymphangitis, orbital cellulitis, osteomyelitis, septic arthritis, necrotising fasciitis or sepsis\n•\tany results from microbiological testing\n•\tany previous antibiotic use, which may have led to resistant bacteria.","1.1.10"]
[null,"Consider taking a swab for microbiological testing from people with cellulitis or erysipelas if the skin is broken and this has not been done already.","1.1.11"]
[null,"If a swab has been sent for microbiological testing:\n•\treview the choice of antibiotic(s) when results are available, and\n•\tchange the antibiotic(s) according to results if symptoms or signs of the infection are not improving, using a narrow spectrum antibiotic if possible. ","1.1.12"]
[null,"Referral and seeking specialist advice"]
[null,"Refer people to hospital if they have any symptoms or signs suggesting a more serious illness or condition, such as orbital cellulitis, osteomyelitis, septic arthritis, necrotising fasciitis or sepsis.","1.1.13"]
[null,"Consider referring people with cellulitis or erysipelas to hospital, or seek specialist advice, if they:\n•\tare severely unwell, or \n•\thave infection near the eyes or nose (including periorbital cellulitis), or\n•\tcould have uncommon pathogens, for example after a penetrating injury, exposure to water-borne organisms, or an infection acquired outside the UK, or\n•\thave spreading infection that is not responding to oral antibiotics, or \n•\tlymphangitis, or\n•\tcannot take oral antibiotics (exploring locally available options for giving intravenous antibiotics at home or in the community, rather than in hospital, where appropriate).","1.1.14"]
[null,"1.2   Choice of antibiotic"]
[null,"When prescribing an antibiotic for cellulitis or erysipelas follow:\n•\ttable 1 for adults aged 18 years and over\n•\ttable 2 for children and young people under 18 years","1.2.1"]
[null,"1.3    Preventing recurrent cellulitis or erysipelas"]
[null,"Do not routinely offer antibiotic prophylaxis to prevent recurrent cellulitis or erysipelas. Give advice about seeking medical help if symptoms of cellulitis or erysipelas develop.","1.3.1"]
[null,"For adults who have had treatment in hospital, or under specialist advice, for at least 2 separate episodes of cellulitis or erysipelas in the previous 12 months, specialists may consider a trial of antibiotic prophylaxis. Involve the person in a shared decision by discussing and taking account of:\n•\tthe severity and frequency of previous symptoms\n•\tthe risk of developing complications\n•\tunderlying conditions (such as oedema, diabetes or venous insufficiency) and their management\n•\tthe risk of resistance with long-term antibiotic use\n•\tthe person’s preference for antibiotic use.","1.3.2"]
[null,"When choosing an antibiotic for prophylaxis (see the recommendations on choice of antibiotic prophylaxis) take account of any previous microbiological results and previous antibiotic use.","1.3.3"]
[null,"When antibiotic prophylaxis is given, give advice about:\n•\tpossible adverse effects of long-term antibiotics\n•\treturning for review within 6 months\n•\tseeking medical help if symptoms of cellulitis or erysipelas recur.","1.3.4"]
[null,"Review antibiotic prophylaxis for recurrent cellulitis or erysipelas at least every 6 months. The review should include:\n•\tassessing the success of prophylaxis\n•\tdiscussing continuing, stopping or changing prophylaxis (taking into account the person’s preferences for antibiotic use and the risk of antimicrobial resistance)\nStop or change the prophylactic antibiotic to an alternative if cellulitis or erysipelas recurs (see recommendation 1.1.4 for treatment of acute infection).","1.3.5"]
[null,"1.4   Choice of antibiotic prophylaxis "]
[null,"When prescribing an antibiotic to prevent recurrent cellulitis or erysipelas in adults, specialists should follow table 3.","1.4.1"]

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[null,"Table 1. Antibiotics for adults aged 18 years and over"]
[]
[null,"Antibiotic1","Dosage and course length2 "]
[null,"First choice antibiotic (give oral unless person unable to take oral or severely unwell)3"]
[null,"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"]
[null,"Alternative first choice antibiotics for penicillin allergy or if flucloxacillin unsuitable (give oral unless person unable to take oral or severely unwell)3"]
[null,"Clarithromycin","500 mg twice a day orally for 5 to 7 days5","or 500 mg twice a day IV6"]
[null,"Erythromycin (in pregnancy)","500 mg four times a day orally for 5 to 7 days5"]
[null,"Doxycycline","200 mg on first day, then 100 mg once a day orally for 5 to 7 days in total5"]
[null,"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"]
[null,"Co-amoxiclav","500/125 mg three times a day orally for 7 days5","or 1.2 g three times a day IV6"]
[null,"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"]
[null,"Clarithromycin with","500 mg twice a day orally for 7 days5","or 500 mg twice a day IV6"]
[null,"Metronidazole","400 mg three times a day orally for 7 days5","or 500 mg three times a day IV6"]
[null,"Alternative choice antibiotics for severe infection"]
[null,"Co-amoxiclav","500/125 mg three times a day orally for 7 days5","or 1.2 g three times a day IV6"]
[null,"Cefuroxime","750 mg to 1.5 g three or four times a day IV6"]
[null,"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"]
[null,"Ceftriaxone (only for ambulatory care8)","2 g once a day IV6"]
[null,"Antibiotics to be added if MRSA infection is suspected or confirmed (combination therapy with an antibiotic listed above)8"]
[null,"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"]
[null,"Teicoplanin9,10","Initially 6 mg/kg every 12 hours for three doses, then 6 mg/kg once a day IV6"]
[null,"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"]
[null,"1 See BNF for appropriate use and dosing in specific populations, for example, hepatic impairment, renal impairment, pregnancy and breast-feeding, and administering intravenous (or, where appropriate, intramuscular) antibiotics."]
[null,"2 Oral doses are for immediate release medicines."]
[null,"3 Give oral antibiotics first-line if the person can take oral medicines, and the severity of their symptoms does not require intravenous antibiotics."]
[null,"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."]
[null,"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."]
[null,"6 If intravenous antibiotics are given, review by 48 hours and consider switching to oral antibiotics if possible for the appropriate course length."]
[null,"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."]
[null,"8 Other antibiotics may be appropriate based on microbiological results and specialist advice."]
[null,"9 See BNF for information on therapeutic drug monitoring."]
[null,"10 See BNF for information on monitoring of patient parameters."]
[null,"Abbreviations: IV, Intravenous; MRSA, Meticillin-resistant Staphylococcus aureus"]
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[null,"Table 2 Antibiotics for children and young people under 18 years"]
[]
[null,"Antibiotic1","Dosage and course length2"]
[null,"Children under 1 month"]
[null,"Antibiotic choice based on specialist advice"]
[null,"Children aged 1 month and over"]
[null,"First choice antibiotic (give oral unless person unable to take oral or severely unwell)3"]
[null,"Flucloxacillin4","1 month to 1 year, 62.5 mg to 125 mg four times a day orally for 5 to 7 days5\n2 to 9 years, 125 mg to 250 mg four times a day orally for 5 to 7 days5\n10 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"]
[null,"Alternative first choice antibiotics for penicillin allergy or if flucloxacillin unsuitable (give oral unless person unable to take oral or severely unwell)3"]
[null,"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)\n1 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)\n6 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)\n12 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\n3 months to 17 years, 30 mg/kg three times a day IV (maximum 1.2 g three times a day)6"]
[null,"Clarithromycin","1 month to 11 years:\nUnder 8 kg, 7.5 mg/kg twice a day orally for 5 to 7 days5\n8 to 11 kg, 62.5 mg twice a day orally for 5 to 7 days5\n12 to 19 kg, 125 mg twice a day orally for 5 to 7 days5\n20 to 29 kg, 187.5 mg twice a day orally for 5 to 7 days5\n30 to 40 kg, 250 mg twice a day orally for 5 to 7 days5\n12 to 17 years:\n250 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\n12 to 17 years, 500 mg twice a day IV6"]
[null,"Erythromycin (in pregnancy)","8 to 17 years, 250 to 500 mg four times a day orally for 5 to 7 days5"]
[null,"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"]
[null,"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)\n1 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)\n6 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)\n12 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\n3 months to 17 years, 30 mg/kg three times a day IV (maximum 1.2 g three times a day)6"]
[null,"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"]
[null,"Clarithromycin","1 month to 11 years:\nUnder 8 kg, 7.5 mg/kg twice a day orally for 7 days5\n8 to 11 kg, 62.5 mg twice a day orally for 7 days5\n12 to 19 kg, 125 mg twice a day orally for 7 days5\n20 to 29 kg, 187.5 mg twice a day orally for 7 days5\n30 to 40 kg, 250 mg twice a day orally for 7 days5\n12 to 17 years:\n250 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\n12 to 17 years, 500 mg twice a day IV6"]
[null,"with (if anaerobes suspected):\nMetronidazole","1 month, 7.5 mg/kg twice a day orally for 7 days5\n2 months to 11 years, 7.5 mg/kg three times a day orally (maximum per dose 400 mg) for 7 days5\n12 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\n2 months to 17 years, 7.5 mg/kg three times a day IV (maximum per dose 500 mg)6"]
[null,"Alternative choice antibiotics for severe infection9"]
[null,"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)\n1 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)\n6 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)\n12 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\n3 months to 17 years, 30 mg/kg three times a day IV (maximum 1.2 g three times a day)6"]
[null,"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 "]
[null,"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 6.25mg/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"]
[null,"Antibiotics to be added if suspected or confirmed MRSA infection (combination therapy with an antibiotic listed above)9"]
[null,"Vancomycin10,11","1 month to 11 years, 10 to 15 mg/kg four times a day IV, adjusted according to serum-vancomycin concentration6\n12 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"]
[null,"Teicoplanin10,11","1 month, initially 16 mg/kg for one dose, then (after 24 hours) 8 mg/kg once a day IV6\n2 months to 11 years, initially 10 mg/kg every 12 hours for 3 doses, then 6 to 10 mg/kg once a day IV6\n12 to 17 years, initially 6 mg/kg every 12 hours for three doses, then 6 mg/kg once a day IV6"]
[null,"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)\n12 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\n12 to 17 years, 600 mg twice a day IV6 "]
[null,"1 See BNF for Children for appropriate use and dosing in specific populations, for example, hepatic impairment, renal impairment, pregnancy and breast-feeding, and administering intravenous (or, where appropriate, intramuscular) antibiotics."]
[null,"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."]
[null,"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."]
[null,"4 If flucloxacillin oral solution is not tolerated because of poor palatability, consider capsules (see Medicines for Children, helping your child to swallow tablets leaflet)."]
[null,"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."]
[null,"6 If intravenous antibiotics are given, review by 48 hours and consider switching to oral antibiotics if possible for the appropriate course length."]
[null,"7 Co-amoxiclav 400/57 suspension may also be considered to allow twice daily dosing (see BNF for Children for dosing information)."]
[null,"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."]
[null,"9 Other antibiotics may be appropriate based on microbiological results and specialist advice."]
[null,"10 See BNF for Children for information on therapeutic drug monitoring."]
[null,"11 See BNF for Children for information on monitoring of patient parameters."]
[null,"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."]
[null,"Abbreviations: IV, Intravenous; MRSA, Meticillin-resistant Staphylococcus aureus"]
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[null,"Table 3. Antibiotic prophylaxis for adults 18 years and over"]
[]
[null,"Antibiotic prophylaxis1,2","Dosage3"]
[null,"First choice"]
[null,"Phenoxymethylpenicillin","250 mg twice a day"]
[null,"Alternative first choice for penicillin allergy"]
[null,"Erythromycin ","250 mg twice a day"]
[null,"Consult local microbiologist for alternative antibiotics"]
[null,"1See BNF for appropriate use and dosing in specific populations, for example, hepatic impairment, renal impairment, pregnancy and breast feeding."]
[null,"2Choose antibiotics according to recent microbiological results where possible. Avoid using the same antibiotic for treatment and prophylaxis."]
[null,"3Doses given are by mouth using immediate release medicines, unless otherwise stated."]