NICE NG190

NICE NG190 (March 2021) is NICE’s antimicrobial prescribing guideline for secondary bacterial infection of eczema (and of other common skin conditions). It covers adults and children; for babies under 1 month, antibiotic choice is left to specialists. It complements NICE CG57, which covers eczema in under-12s generally, and NICE NG141 for Cellulitis. Its main message for parents of a toddler is that weeping, crusting eczema is not always infected. NICE notes that eczema is often colonised by bacteria such as Staphylococcus aureus without being clinically infected, and that a flare will not respond to antibiotics unless bacteria are driving it.

NICE [defines] NICE NG190 NICE NG190 [part-of] NICE CG57 NICE NG190 [defines] Infected Eczema Staphylococcus aureus [relates] Infected Eczema

Key recommendations for children. Signs of infection include weeping, pustules, crusts, rapidly worsening eczema, failure to respond to treatment, fever and malaise. Do not routinely swab at first presentation. In a child who is not systemically unwell, do not routinely offer either a topical or an oral antibiotic. The committee found antibiotics added little benefit over Topical Corticosteroids alone, and repeated courses add to Antimicrobial Resistance. Whether or not antibiotics are given, keep using emollients and topical steroids (Emollient Therapy). If a child is systemically unwell, offer an oral antibiotic.

NICE NG190 [opposes] Antimicrobial Resistance NICE NG190 [supports] Topical Corticosteroids NICE NG190 [supports] Emollient Therapy

Choice of antibiotic (under-18 table). If a topical antibiotic is appropriate (localised, not severe), the first choice is Fusidic Acid 2% three times a day for 5–7 days. Use it for localised infection only, because extended or repeated use breeds resistance. The first oral choice is Flucloxacillin for 5–7 days: 62.5–125 mg four times daily from 1 month to 1 year, and 125–250 mg four times daily at 2–9 years. For penicillin allergy, or if flucloxacillin is unsuitable, Clarithromycin is dosed by weight, e.g. 62.5 mg twice daily at 8–11 kg and 125 mg twice daily at 12–19 kg. If MRSA is suspected, a microbiologist should be consulted. Parent preference for liquid versus cream counts in the choice.

NICE NG190 [treats] Infected Eczema Fusidic Acid [treats] Infected Eczema Flucloxacillin [treats] Infected Eczema Clarithromycin [treats] Infected Eczema

Reassessment and referral. Reassess if the child becomes unwell, has pain out of proportion to the rash, worsens rapidly, or is not better after the course. At that point, consider Eczema Herpeticum, cellulitis, necrotising fasciitis or sepsis. Swab infections that are worsening or not improving. For frequently recurring infection, swab the skin, consider a nasal swab and start decolonisation. Refer to hospital if there are signs of serious illness, and consider specialist advice for spreading infection despite oral antibiotics or for frequent recurrences (When to Refer). The companion impetigo guideline is NICE NG153.

Eczema Herpeticum [relates] Infected Eczema NICE NG190 [precedes] When to Refer NICE NG190 [relates] NICE NG153

Herpes looks like "infected eczema"

NG190 tells clinicians to reconsider eczema herpeticum when “infected eczema” fails to improve. Punched-out erosions, clustered blisters or a rapidly spreading painful rash in a toddler need same-day medical review, not another antibiotic course.

Connections

• Infected Eczema — defines signs and treatment, source: NICE NG190
• Staphylococcus aureus — antibiotic stewardship for staph infection, source: NICE NG190
• NICE NG153 — companion impetigo guideline (hydrogen peroxide first), source: NICE NG153
• Fusidic Acid — first-choice topical, 5–7 days, localised only, source: NICE NG190
• Flucloxacillin — first-choice oral; 2–9 y 125–250 mg QDS, source: NICE NG190
• Clarithromycin — weight-based alternative for penicillin allergy, source: NICE NG190
• Eczema Herpeticum — differential when infection fails to improve, source: NICE NG190
• NICE CG57 — parent guideline for under-12 eczema care, source: NICE NG190
• Antimicrobial Resistance — rationale against routine antibiotics, source: NICE NG190
• Cellulitis — follow NG141 if cellulitis signs, source: NICE NG190