Human and animal bites: antimicrobial prescribing

This guideline sets out an antimicrobial prescribing strategy for human and animal bites (excluding insect bites) in adults, young people and children aged 72 hours and over. It aims to optimise antibiotic use and reduce antibiotic resistance.

# Recommendations

# Managing human and animal bites

## Assessment
For people with a human or animal bite:
assess the type and severity of the bite, including what animal caused the bite, the site and depth of the wound, and whether it is infected (see the recommendation on taking a swab in the section on treating infected bites)
assess the risk of tetanus, rabies or a bloodborne viral infection and take appropriate action
manage the wound with irrigation and debridement as necessary
be aware of potential safeguarding issues in vulnerable adults and children, for example, as outlined in NICE's guidelines on child maltreatment, challenging behaviour and learning disabilities and domestic violence and abuse.Also see the recommendations on referral and seeking specialist advice.
Seek specialist advice from a microbiologist for bites from a wild or exotic animal (including birds and non-traditional pets) because the spectrum of bacteria involved may be different, and there may be a risk of other serious non-bacterial infections.
Consider seeking specialist advice from a microbiologist for domestic animal bites (including farm animal bites), that you are unfamiliar with.
For a short explanation of why the committee made these recommendations, see the rationale section on assessment .
For more details, see the evidence review.
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## Antibiotic prophylaxis for uninfected bites
Do not offer antibiotic prophylaxis to people with a human bite that has not broken the skin.
Offer antibiotic prophylaxis (see the recommendations on choice of antibiotic) to people with a human bite that has broken the skin and drawn blood.
Consider antibiotic prophylaxis for people with a human bite that has broken the skin but not drawn blood if it:
involves a high-risk area such as the hands, feet, face, genitals, skin overlying cartilaginous structures or an area of poor circulation or
is in a person at risk of a serious wound infection because of a comorbidity (such as diabetes, immunosuppression, asplenia or decompensated liver disease).
Do not offer antibiotic prophylaxis to people with a cat bite that has not broken the skin.
Offer antibiotic prophylaxis (see the recommendations on choice of antibiotic) to people with a cat bite that has broken the skin and drawn blood.
Consider antibiotic prophylaxis for people with a cat bite that has broken the skin but not drawn blood if the wound could be deep.
Do not offer antibiotic prophylaxis to people with a bite from a dog or other traditional pet (excluding cat bites) that:
has not broken the skin or
has broken the skin but not drawn blood.
Offer antibiotic prophylaxis (see the recommendations on choice of antibiotic) to people with a bite from a dog or other traditional pet (excluding cat bites) that has broken the skin and drawn blood if it:
has penetrated bone, joint, tendon or vascular structures or
is deep, is a puncture or crush wound, or has caused significant tissue damage or
is visibly contaminated (for example, if there is dirt or a tooth in the wound).
Consider antibiotic prophylaxis (see the recommendations on choice of antibiotic) for people with a bite from a dog or other traditional pet (excluding cat bites) that has broken the skin and drawn blood if it:
involves a high-risk area such as the hands, feet, face, genitals, skin overlying cartilaginous structures or an area of poor circulation or
is in a person at risk of a serious wound infection because of a comorbidity (such as diabetes, immunosuppression, asplenia or decompensated liver disease).
For a short explanation of why the committee made these recommendations, see the rationale section on antibiotic prophylaxis for uninfected human and animal bites .
For more details, see the evidence review.
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## Treating infected bites
Take a swab for microbiological testing to guide treatment if there is discharge (purulent or non-purulent) from the human or animal bite wound.
Offer an antibiotic (see the recommendations on choice of antibiotic) for people with a human or animal bite if there are symptoms or signs of infection, such as increased pain, inflammation, fever, discharge or an unpleasant smell.
For a short explanation of why the committee made these recommendations, see the rationale section on treating infected human and animal bites .
For more details, see the evidence review.
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## Advice
Give advice to people with a human or animal bite about:
possible adverse effects of antibiotics (if they have been offered antibiotics)
seeking medical help if symptoms or signs of infection develop or worsen rapidly or significantly at any time, or do not start to improve within 24 to 48 hours of starting treatment.

## Reassessment
Reassess the human or animal bite if:
symptoms or signs of infection develop or worsen rapidly or significantly at any time, or do not start to improve within 24 to 48 hours of starting treatment or
the person becomes systemically unwell or
the person has severe pain that is out of proportion to the infection.
Be aware that people who have difficulty communicating may have non-verbal signs of pain, such as a change in behaviour.
If a skin swab has been sent for microbiological testing, review the choice of antibiotic based on the swab results. If a change of antibiotic is needed, use 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.
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## Referral and seeking specialist advice
Refer people with a human or animal bite to hospital if they have:
symptoms or signs suggesting a more serious illness or condition (these include severe cellulitis, abscess, osteomyelitis, septic arthritis, necrotising fasciitis or sepsis) or
a penetrating wound involving arteries, joints, nerves, muscles, tendons, bones or the central nervous system.
Consider referral or seeking specialist advice for people with a human or animal bite if:
they are systemically unwell or
they have developed symptoms or signs of infection after taking prophylactic antibiotics or
they have lymphangitis or
they are at risk of a serious wound infection because of a pre-existing medical condition or
they cannot take oral antibiotics (in which case, explore with the specialist whether locally available options for parenteral antibiotics at home or in the community, rather than in hospital, are appropriate) or
the bite is infected and is not responding to oral antibiotics or
the bite is in an area of poor circulation.
For a short explanation of why the committee made these recommendations, see the rationale section on referral and seeing specialist advice .
For more details, see the evidence review.
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# Choice of antibiotic
When prescribing an antibiotic for a bite from a human, cat, dog or other traditional pet:
follow table 1 for adults aged 18 years and over
follow table 2 for children and young people under 18 years.
Give oral antibiotics if the person can take oral medicines, and the severity of their condition does not need intravenous antibiotics.
If intravenous antibiotics are given, review within 48 hours and consider switching to oral antibiotics if possible.
Prophylaxis and treatment
Antibiotic, dosage and course length for prophylaxis (3 days) and treatment (5 days)
First-choice oral antibiotic
Coamoxiclav:
/125 mg or 500/125 mg three times a day
Alternative first-choice oral antibiotics for penicillin allergy or if coamoxiclav is unsuitable
Doxycycline:
mg on first day, then 100 mg or 200 mg daily
with
Metronidazole:
mg three times a day
Alternative first-choice oral antibiotics in pregnancy for penicillin allergy or if coamoxiclav is unsuitable
Seek specialist advice
First-choice intravenous antibiotic (if unable to take oral antibiotics or severely unwell)
Coamoxiclav:
g three times a day
Alternative first-choice intravenous antibiotics for penicillin allergy or if coamoxiclav is unsuitable
Cefuroxime (caution in penicillin allergy):
mg three times a day (increased to 750 mg four times a day or 1.5 g three or four times a day if infection is severe)
with
Metronidazole:
mg three times a day
Ceftriaxone (caution in penicillin allergy)
g once a day
with
Metronidazole:
mg three times a day
If cephalosporin is not appropriate
Seek specialist advice
See the BNF and summary of product characteristics for appropriate use and dosing in specific populations, for example, for people with hepatic or renal impairment, in pregnancy and breastfeeding, and when administering intravenous (or, if appropriate, intramuscular) antibiotics.
A 5day course is appropriate for treating most human or animal bites, but course length can be increased to 7 days (with review) based on clinical assessment of the wound, for example, if there is significant tissue destruction or it has penetrated bone, joint, tendon or vascular structures.
Prophylaxis and treatment
Antibiotic, dosage and course length for prophylaxis (3 days) and treatment (5 days)
Choice for children under 1 month
Seek specialist advice
First-choice oral antibiotic for children aged 1 month and over
Coamoxiclav:
month to 11 months: 0.25 ml/kg of 125/31 suspension three times a day
year to 5 years: 0.25 ml/kg or 5 ml of 125/31 suspension three times a day
years to 11 years: 0.15 ml/kg or 5 ml of 250/62 suspension three times a day
years to 17 years: 250/125 mg or 500/125 mg three times a day
Coamoxiclav 400/57 suspension may also be considered to allow for twice-daily dosing
Alternative first-choice oral antibiotic for children under 12 years for penicillin allergy or if coamoxiclav is unsuitable
Cotrimoxazole (off-label use):
weeks to 5 months: 120 mg or 24 mg/kg twice a day
months to 5 years: 240 mg or 24 mg/kg twice a day
years to 11 years: 480 mg or 24 mg/kg twice a day
See the BNF for Children for information on monitoring
Alternative first-choice oral antibiotics for young people aged 12 to 17 years for penicillin allergy or if coamoxiclav is unsuitable
Doxycycline:
mg on first day, then 100 mg or 200 mg daily
with
Metronidazole:
mg three times a day
Alternative first-choice oral antibiotics in pregnancy for penicillin allergy or if coamoxiclav unsuitable
Seek specialist advice
First-choice intravenous antibiotic (if unable to take oral antibiotics or severely ill)
Coamoxiclav:
month to 2 months: 30 mg/kg twice a day
months to 17 years: 30 mg/kg three times a day (maximum per dose 1.2g)
Alternative first-choice intravenous antibiotics for penicillin allergy or if coamoxiclav is unsuitable
Cefuroxime (caution in penicillin allergy):
month to 17 years: 20 mg/kg three times a day (maximum 750 mg per dose), which can be increased to 50 mg/kg to 60 mg/kg three or four times a day (maximum per dose 1.5 g)
with
Metronidazole:
month: loading dose 15 mg/kg, then (after 8 hours) 7.5 mg/kg three times a day
months to 17 years: 7.5 mg/kg three times a day (maximum per dose 500 mg)
Ceftriaxone (caution in penicillin allergy):
month to 11 years (up to 50 kg): 50 mg/kg to 80 mg/kg once a day (maximum 4 g per day)
years to 11 years (50 kg and above) and 12 years to 17 years: 1 g to 2 g once a day
with
Metronidazole:
month: loading dose 15 mg/kg, then (after 8 hours) 7.5 mg/kg three times a day
months to 17 years: 7.5 mg/kg three times a day (maximum per dose 500 mg)
If a cephalosporin is not appropriate
Seek specialist advice
See the BNF for Children and summary of product characteristics for appropriate use and dosing in specific populations, for example, for people with hepatic or renal impairment, in pregnancy and breastfeeding, and when administering intravenous (or, if appropriate, intramuscular) antibiotics.
A 5day course is appropriate for treating most human or animal bites, but course length can be increased to 7 days (with review) based on clinical assessment of the wound, for example, if there is significant tissue destruction or it has penetrated bone, joint, tendon or vascular structures.
For off-label use, 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.
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.
Loading. Please wait.# Rationales
The recommendations in this guideline are based on the evidence identified and the experience of the committee.

# Assessment

## Why the committee made the recommendations
Recommendations 1.1.1 to 1.1.3
The committee agreed that it was good practice to assess and manage the wound in line with NICE's clinical knowledge summary on human and animal bites. They also agreed that, for human and animal bites, healthcare professionals should also consider potential safeguarding issues for vulnerable adults and children in line with NICE guidelines.
There was only evidence on managing bites from humans, dogs and cats; no evidence was identified for bites from other animal species. The committee agreed that it was reasonable to extrapolate this evidence to bites from other animals traditionally kept as pets, such as rabbits and hamsters. The committee agreed that specialist advice should be sought for bites from wild and exotic animals (including birds and non-traditional pets), such as snakes, lizards, monkeys or bats. This was because there may be a different spectrum of bacteria involved and a risk of other serious non-bacterial infections. For example, monkey bites are associated with herpes B virus, which may have serious consequences if not treated early, including fatal encephalomyelitis or severe neurological impairment. Healthcare professionals may also wish to seek specialist advice for domestic animal bites (including farm animal bites) they are not familiar with.
Return to the recommendations

# Antibiotic prophylaxis for uninfected human and animal bites

## Why the committee made the recommendations
Recommendations 1.1.4 to 1.1.12
Evidence was only identified for antibiotic prophylaxis after a dog, cat or human bite, and it was limited and of low quality. The committee agreed that, if a bite has not broken the skin, antibiotic prophylaxis is not needed. Many bites are superficial abrasions, meaning that they break the skin but do not draw blood. These bites are at low risk of infection because the dermis will not have been penetrated, so do not always need antibiotic prophylaxis.
The committee went on to discuss and agree when antibiotic prophylaxis should either be offered, considered, or not offered for a human, cat or dog (or other traditional pet) bite, based on the evidence and their knowledge of the risk of infection.
The committee discussed the pooled evidence on human bites, which suggested that antibiotic prophylaxis was more effective than placebo at reducing the incidence of infection. They discussed that a human bite that has broken the skin is at high risk of infection and other serious consequences because of the associated oral bacteria. However, they also discussed that the site and depth of a bite affects the risk of infection. In a study of human bites to the hand, antibiotic prophylaxis was particularly effective. The committee discussed that wounds to the hand have a higher risk of infection because of the multiple small compartments and number of joints. The same high level of infection risk applies to the feet and skin overlying cartilaginous structures.
The committee went on to discuss the evidence for human bites that are at lower risk of infection, as outlined in Broder et al. (2004). These bites penetrated only the epidermis (that is, they broke the skin but did not draw blood) and did not involve the high-risk areas of the hands, feet, or skin overlying joints or cartilaginous structures. For this study, there was a very low rate of infection; signs of infection were seen in 1 of 62 people in the placebo group and none of the 63 people taking antibiotics.
The committee agreed that, if a human bite has not broken the skin, antibiotic prophylaxis should not be offered. If it has broken the skin and drawn blood, antibiotic prophylaxis should be offered. The committee agreed that, for people with a human bite that has broken the skin but not drawn blood, antibiotic prophylaxis is not routinely needed. However, they agreed that it can be considered for bites in high-risk areas or in people at risk of a serious wound infection because of a comorbidity.
The committee went on to discuss when antibiotic prophylaxis should be offered for a cat bite. The evidence on cat bites, which was based on a very small sample size of 11 did not show a statistically significant difference between antibiotic prophylaxis and placebo in reducing the incidence of infection in cat bites. Based on such limited data, the committee could not judge the certainty of the evidence. However, based on their expertise and experience, they agreed that antibiotic prophylaxis should be offered if a cat bite has broken the skin and drawn blood. Cat bites are at high risk of infection because of cat oral bacteria and because the needle-like nature of the wounds (small, deep punctures) is hard to irrigate. The committee went on to discuss that this type of wound is often deeper than it appears, which can cause assessment difficulties. They also noted that infection in deep skin structures is possible, which has serious consequences such as bone infections. The committee agreed that antibiotic prophylaxis is not needed if a cat bite has not broken the skin. However, it can be considered if the cat bite has broken the skin but not drawn blood if, despite appearances and the lack of blood, the wound could still be deep.
The committee went on to discuss and agree situations when antibiotic prophylaxis should be offered for a dog bite (or a bite from another traditional pet other than a cat). Evidence suggested no difference between antibiotic prophylaxis and placebo in reducing the incidence of infection based on the type and location of the dog bite wound. However, based on their experience, the committee agreed that antibiotic prophylaxis should be offered for a dog bite (or a bite from another traditional pet) if it:
has broken the skin and penetrated bone, joint, tendon or vascular structures or
is deep, a puncture or crush wound, or has caused significant tissue damage or
is visibly contaminated (for example, if there is dirt or a tooth in the wound).
They also agreed that antibiotic prophylaxis could be considered for a dog bite (or a bite from another traditional pet other than a cat) that has broken the skin and drawn blood if it involves a high-risk area or is in a person at risk of a serious wound infection because of a comorbidity. The committee agreed that the principles of the evidence from Broder et al. (2004) on human bites could be extrapolated to bites from dogs or other traditional pets). The committee discussed that antibiotic prophylaxis would only be considered for a dog bite (or a bite from another traditional pet) fulfilling these criteria because, in their experience, these bites have a lower risk of infection than human bites. This is supported by the evidence that showed no difference between antibiotic prophylaxis and placebo in reducing the incidence of infection after a dog bite. Antibiotic prophylaxis is not needed for a dog bite (or a bite from another traditional pet) that has not broken the skin, or has only caused a superficial wound that has broken the skin but not drawn blood.
For more details, see the summary of the evidence on antibiotics.
Return to the recommendations

# Treating infected human and animal bites

## Why the committee made the recommendations
Recommendations 1.1.13 to 1.1.14
There was no evidence on the treatment of human or animal bites. However, the committee agreed that antibiotics should be offered for human or animal bites with symptoms or signs of infection because of the potential consequences of not treating an infected bite.
The committee also agreed that, if there is discharge from the bite wound this should be swabbed and sent for microbiological testing before antibiotics are taken. This includes purulent and non-purulent discharge because certain bacteria associated with a human or animal bite, such as Eikenella, may not form pus.
For more details, see the summary of the evidence on antibiotics.
Return to the recommendations

# Reassessment

## Why the committee made the recommendations
Recommendations 1.1.16 to 1.1.18
The committee agreed that a human or animal bite should be reassessed if an infection develops or worsens rapidly or significantly at any time or does not start to improve within 24 to 48 hours of starting treatment because of the consequences of complications from an infection. Reassessment is also recommended if the person becomes systemically unwell or has severe pain that is out of proportion to the infection (which can be a symptom of necrotising fasciitis).
The committee agreed that it is good antimicrobial stewardship to review and potentially change the antibiotic used when microbiological testing results are available. A narrow-spectrum antibiotic should be used if appropriate.
They also discussed that reassessment is another opportunity to reconsider potential safeguarding issues for vulnerable adults or children, and to consider non-verbal signs of pain, such as a change in behaviour, in people who have difficulty communicating.
Return to the recommendations

# Referral and seeking specialist advice

## Why the committee made the recommendations
Recommendations 1.1.19 to 1.1.20
The committee agreed that people with a human or animal bite should be referred to hospital if they have symptoms or signs of a more serious illness or condition, or if they have penetrating wounds with certain features because of the serious consequences of these.
The committee agreed other circumstances when the prescriber may want to refer the person or seek specialist advice.
Return to the recommendations

# Choice of antibiotic
Recommendations 1.2.1 to 1.2.3

## Why the committee made the recommendations
No evidence was found comparing different antibiotics to inform the choice of antibiotic for human and animal bites. Therefore, the committee based these recommendations on their experience, current practice, antimicrobial resistance, and the need to provide choices that cover the relevant range of likely aerobic and anaerobic pathogens in human and animal bites.
The committee agreed that the same antibiotic choices should be available for both prophylaxis and treatment because the pathogens will be the same.
The committee agreed that the first-choice oral antibiotic for all people with a human or animal bite is coamoxiclav, which has good activity against the relevant range of likely pathogens.
The committee were aware of the BNF entry for coamoxiclav. Advice was also sought from the UK Teratology Information Service (UKTIS), which confirmed that the association between coamoxiclav and necrotising enterocolitis has only been identified in the context of prelabour premature rupture of the membranes (PPROM). Outside of this, there is no evidence to show that general coamoxiclav use in pregnancy is associated with an increased risk of necrotising enterocolitis. UKTIS advised that there should be no restriction around the use of coamoxiclav in pregnancy, provided it is not being given for PPROM. It was agreed that human or animal bites are a suitable clinical indication for coamoxiclav use in pregnancy.
If coamoxiclav is unsuitable, the alternative first-choice oral antibiotics for adults and young people over 12 years are doxycycline with metronidazole (an antibiotic with high activity against anaerobic bacteria). If coamoxiclav is unsuitable and a woman is pregnant, specialist advice should be sought for an alternative antibiotic with good activity against Pasteurella.
The committee agreed that if coamoxiclav is unsuitable, the alternative first-choice oral antibiotic for children under 12 years is cotrimoxazole because this also has good activity against the range of likely pathogens.
The committee agreed that intravenous antibiotics should only be used if a person cannot take oral antibiotics or the severity of their condition warrants intravenous antibiotics. The first-choice intravenous antibiotic for all people with a human or animal bite is coamoxiclav because it has good activity against the relevant range of likely pathogens.
If coamoxiclav is unsuitable, the alternative first-choice intravenous antibiotics for all people with a human or animal bite are:
cefuroxime with metronidazole
ceftriaxone with metronidazole.
The committee agreed that both options have good activity against the relevant likely pathogens. The cephalosporins, cefuroxime and ceftriaxone have a similar spectrum of activity but providing more than 1 option allows for choice to be made locally. If a cephalosporin is not appropriate, for example, in people with a history of immediate hypersensitivity to penicillins, the committee agreed that a local microbiologist should be consulted to suggest a suitable alternative.
There was no evidence comparing antibiotic dosage, course length and route of administration. Therefore, the recommendations were based on the committee's experience and current practice. The committee agreed that the shortest course that is likely to be effective should be prescribed to reduce the risk of antimicrobial resistance and adverse effects. However, because the type and severity of bites can vary, a longer course may be needed based on clinical assessment of the wound.
The committee agreed that, for both oral and intravenous routes of administration (which would be switched to oral antibiotics when possible), a course length of 3 days should be effective for prophylaxis, and a course length of 5 days should be effective for treatment. However, the committee discussed that because the type and severity of bites can vary, a longer course of up to 7 days (with review) may be needed. This would be based on a clinical assessment of the wound, and whether it has, for example, caused significant tissue destruction or penetrated bone, joint, tendon or vascular structures.
Return to the recommendations# Context
Human and animal bites are at risk of infection. Human bites are most commonly infected by Streptococcus, Staphylococcus aureus, Haemophilus, Eikenella corrodens, Bacteroides and other anaerobes. Most infections from animal bites are polymicrobial and contain both aerobic and anaerobic organisms. Causative organisms for infections from cat and dog bites (the most common animal bites) include Pasteurella, Streptococcus, Staphylococcus, Neisseria, Corynebacterium, Fusobacterium nucleatum and Bacteroides (Abrahamian et al. 2011).# Summary of the evidence
This is a summary of the evidence, for full details see the evidence review.
The evidence included 1 systematic review (Medeiros et al. 2001) and 2 randomised controlled trials (Quinn et al. 2010, Broder et al. 2004). These studies considered various prophylactic antibiotics compared with no antibiotic or placebo for managing animal and human bites. No evidence was identified for choice of antibiotic, course length or route of administration.

# Antibiotic efficacy
If no route of administration for an antibiotic is given in the evidence review, no details were reported in the primary study.

## For human bites
Prophylactic antibiotics (oral cefaclor, intravenous cefazolin, intravenous benzylpenicillin, and oral cefalexin or penicillin) were shown to be more effective than placebo at reducing signs of infection after human bites in adults.

## For animal bites
There was no difference between prophylactic antibiotics (oral phenoxymethylpenicillin, oral dicloxacillin, oxacillin, oral cefalexin, oral erythromycin, cotrimoxazole, cloxacillin and oral coamoxiclav) and no treatment or placebo in signs of infection after dog bites in adults, young people and children.
One small study suggests that there was no difference between a prophylactic antibiotic (oxacillin) and placebo in signs of infection after cat bites in adults.

## By bite type
There was no difference between prophylactic antibiotics (oxacillin, oral phenoxymethylpenicillin, oral dicloxacillin, oral cefalexin and oral erythromycin) and no treatment or placebo in the incidence of infection in adults, young people and children when treating puncture, laceration or avulsion wounds.

## By bite location
There was no difference between prophylactic antibiotics (oral dicloxacillin, oral cefalexin, oral erythromycin, oral phenoxymethylpenicillin, cotrimoxazole, oral cefaclor, intravenous cefazolin and intravenous penicillin) and no treatment or placebo in the incidence of infection in adults, young people and children when treating trunk, head and neck, hand or arm wounds.

# Choice of antibiotic
There was no evidence identified about the choice of antibiotic.

# Course length
There was no evidence identified about the course length of antibiotics.

# Route of administration
There was no evidence identified about the route of administration of antibiotics.# Other considerations

# Medicines safety
Antibiotic-associated diarrhoea is estimated to occur in 2% to 25% of people taking antibiotics, depending on the antibiotic used (NICE clinical knowledge summary on diarrhoea  antibiotic associated).
About 10% of the general population claim to have a penicillin allergy; this is often because of a skin rash that occurred while taking a course of penicillin as a child. Fewer than 10% of people who think they are allergic to penicillin are truly allergic. See the NICE guideline on drug allergy: diagnosis and management for more information. People with a history of immediate hypersensitivity to penicillins may also react to cephalosporins and other beta lactam antibiotics (BNF information on phenoxymethylpenicillin).
Cholestatic jaundice can occur with coamoxiclav, and is more common in people over 65 years and in men; treatment should not usually exceed 14 days (BNF information on co-amoxiclav).
Tetracyclines (for example, doxycycline) can deposit in growing bone and teeth (by binding to calcium) causing staining and occasionally dental hypoplasia. They should not be given to pregnant or breastfeeding women, and use in children under 12 years is either contraindicated or there is a caution for use only in severe or life-threatening infections when there are no alternatives (BNF information on doxycycline).
Cotrimoxazole is associated with rare but serious side effects, including blood disorders and StevensJohnson syndrome. There is caution for use in older people because there is an increased risk of serious side effects. There is also caution for use in people with a predisposition to hyperkalaemia. Monitoring of blood counts is recommended with prolonged treatment (BNF information on co-trimoxazole).
See the summaries of product characteristics for information on contraindications, cautions and adverse effects of individual medicines.

# Medicines adherence
Medicines adherence may be a problem for some people taking antibiotics that need frequent dosing or longer treatment duration (see the NICE guideline on medicines adherence).

# Resource implications
Recommended antibiotics are available as generic formulations. See the NHS Drug Tariff for costs.
See the evidence review for more information.