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Knowledge Base

NHSE Pharmacy First PGDs

Characteristics of staff
Qualifications and professional registration
  • Registered healthcare professional listed in the legislation as able to practice under Patient Group Directions.
Initial training
  • The registered healthcare professional authorised to operate under this PGD must have undertaken appropriate education and training and be competent to undertake clinical assessment of patients ensuring safe provision of the medicines listed in accordance with the specification.
  • To deliver this service, the registered healthcare professional should have evidence of competence in the clinical skills and knowledge covered in the Centre for Pharmacy Postgraduate Education (CPPE) Pharmacy First Service self-assessment framework.
  • Before commencement of the service, the pharmacy contractor must ensure that pharmacists and pharmacy staff providing the service are competent to do so and be familiar with the clinical pathways, clinical protocol and PGDs. This may involve completion of training
Competency assessment
  • Individuals operating under this PGD must be assessed as competent or complete a self-declaration of competence to operate under this PGD (see an example authorisation record sheet in Appendix A) [Pharmacy First PGD master authorisation sheet]
  • Individuals operating under this PGD are advised to review their competency using the NICE Competency Framework for health professionals using patient group directions.
Ongoing training and competency
  • Individuals operating under this PGD are personally responsible for ensuring they remain up to date with the use of all medicines and guidance included in the PGD - if any training needs are identified these should be discussed with the senior individual responsible for authorising individuals to act under the PGD and further training provided as required.

The decision to supply any medication rests with the individual registered health professional who must abide by the PGD and any associated organisational policies.

Otigo®
Otigo®
Clinical condition or situation to which this PGD applies

Local symptomatic relief of pain from acute otitis media (AOM) in children aged 1 year and over and young people (under 18 years of age).

Criteria for inclusion
  • Informed consent
  • Individuals aged 1 year and over and under 18 years of age
  • Signs and symptoms of acute otitis media using the appropriate NICE CKS guidance:
    • In older children: earache
    • In younger children: holding, tugging or rubbing of the ear(s) (also non-specific symptoms: fever, crying, poor feeding, restlessness, behavioural changes, cough or rhinorrhoea may also be present)
    AND (on otoscopic examination):
    • Distinctly red, yellow or cloudy tympanic membrane OR
    • Moderate-severe bulging of the tympanic membrane, with loss of normal landmarks and an air-fluid level behind the tympanic membrane.
  • Pain not adequately controlled with regular doses of (over the counter) paracetamol or ibuprofen, using a dosing schedule appropriate for the age and weight of the child. (For further information see: Mild to moderate pain and NSAIDs-prescribing issues).
  • Individuals with moderate – severe symptoms.
Exclusions & Additional Prescribing Details Links
  • Criteria for exclusion
  • Cautions including any relevant action to be taken
  • Specific information for suspected infection to be provided
  • Action to be taken if the individual is excluded
  • Action to be taken if the individual/carer/parent/guardian declines treatment
  • Arrangements for referral for medical advice: Refer to the appropriate medical practitioner in the care pathway.
Description of treatment
  • Name, strength & formulation of drug
    • Otigo® (phenazone 40mg/lidocaine hydrochloride 10mg/g) ear drops, solution
  • Legal category
    • POM
  • Route / method of administration
    • Topically into the external auditory canal of the affected ear(s) instilled into the affected ear(s) via a dropper applicator (provided with bottle).
    • Advise individual/carer/parent/guardian to warm the bottle between their hands before each use.
    • Further advice re: administration can be found in the patient information leaflet (PIL). Further guidance on how to administer ear drops to children is available from Medicines for Children.
  • Off-label use
  • Dose and frequency of administration
    • Children over 1 year of age and young people under 18 years of age:
      • Instil 4 drops up to three times daily into the external auditory canal of the affected ear(s).
      • Further advice re: administration can be found in the patient information leaflet (PIL). Further guidance on how to administer ear drops to children is available from Medicines for Children.
  • Duration of treatment
    • Until symptoms have resolved or up to a maximum of 7 days
  • Quantity to be supplied
  • Storage
  • Drug interactions
  • Identification & management of adverse reactions
  • Management of and reporting procedure for adverse reactions
  • Written information to be given to individual/carer/parent/guardian
  • Individual advice / follow up treatment
  • Records
Amoxicillin
Amoxicillin
Clinical condition or situation to which this PGD applies

Acute otitis media in children aged 1 year and over and young people (under 18 years of age)

Criteria for inclusion
  • Informed consent
  • Individuals aged 1 year and over and under 18 years of age:
    • Individuals under 2 years of age with bilateral (in both ears) acute otitis media AND
      • Symptoms for > 3 days OR
      • Severe symptoms based on clinical global impression
    OR
    • Individuals under 18 years of age with acute otitis media and otorrhea (discharge after eardrum perforation)
  • Signs and symptoms of acute otitis media using the appropriate NICE CKS guidance:
    • In older children: earache
    • In younger children: holding, tugging or rubbing of the ear(s) (also non-specific symptoms: fever, crying, poor feeding, restlessness, behavioural changes, cough or rhinorrhoea may also be present)
    AND (on otoscopic examination):
    • Distinctly red, yellow or cloudy tympanic membrane OR
    • Moderate-severe bulging of the tympanic membrane, with loss of normal landmarks and an air-fluid level behind the tympanic membrane.
    • Perforation of the tympanic membrane and/or sticky discharge in the external auditory canal.
Exclusions & Additional Prescribing Details Links
  • Criteria for exclusion
  • Cautions including any relevant action to be taken
  • Specific information for suspected infection to be provided
  • Action to be taken if the individual is excluded
  • Action to be taken if the individual/carer/parent/guardian declines treatment
  • Arrangements for referral for medical advice: Refer to the appropriate medical practitioner in the care pathway.
Description of treatment
  • Name, strength & formulation of drug
    • Amoxicillin 250mg capsules
    • Amoxicillin 500mg capsules
    • Amoxicillin 125mg/5mL oral suspension (or oral solution) x 100mL
    • Amoxicillin 125mg/5mL sugar free oral suspension (or oral solution) x 100mL
    • Amoxicillin 250mg/5mL oral suspension (or oral solution) x 100mL
    • Amoxicillin 250mg/5mL sugar free oral suspension (or oral solution) x 100mL
    • Amoxicillin 500mg/5mL sugar free oral suspension (or oral solution) x 100mL
  • Legal category
    • POM
  • Route / method of administration
    • Orally, taken with food or water. Capsules should be swallowed whole.
  • Off-label use
  • Dose and frequency of administration
    • Children 1–4 years:
      • 250mg three times a day (every 8 hours)
    • Children 5-17 years:
      • 500mg three times a day (every 8 hours)
  • Duration of treatment
    • 5 days
    • Treatment should be started immediately and 5 days of treatment completed.
  • Quantity to be supplied
  • Storage
  • Drug interactions
  • Identification & management of adverse reactions
  • Management of and reporting procedure for adverse reactions
  • Written information to be given to individual/carer/parent/guardian
  • Individual advice / follow up treatment
  • Records
Clarithromycin
Clarithromycin
Clinical condition or situation to which this PGD applies

Acute otitis media in children aged 1 year and over and young people (under 18 years of age), where amoxicillin is not appropriate due to hypersensitivity.

Criteria for inclusion
  • Informed consent
  • Individuals aged 1 year and over and under 18 years of age:
    • Individuals under 2 years of age with bilateral (in both ears) acute otitis media AND
      • Symptoms for > 3 days OR
      • Severe symptoms based on clinical global impression
    OR
    • Individuals under 18 years of age with acute otitis media and otorrhea (discharge after eardrum perforation)
  • Signs and symptoms of acute otitis media using the appropriate NICE CKS guidance:
    • In older children: earache
    • In younger children: holding, tugging or rubbing of the ear(s) (also non-specific symptoms: fever, crying, poor feeding, restlessness, behavioural changes, cough or rhinorrhoea may also be present)
    AND (on otoscopic examination):
    • Distinctly red, yellow or cloudy tympanic membrane OR
    • Moderate-severe bulging of the tympanic membrane, with loss of normal landmarks and an air-fluid level behind the tympanic membrane.
    • Perforation of the tympanic membrane and/or sticky discharge in the external auditory canal.
  • Known hypersensitivity to amoxicillin, any penicillin or any of the components within the formulation of amoxicillin - see Summary of Product Characteristics. Acceptable sources of allergy information include individual/carer/parent/guardian or National Care Record.
    OR
  • History of severe immediate hypersensitivity reaction (e.g. anaphylaxis) to another beta-lactam antibiotic (e.g. cephalosporin, carbapenem or monobactam). Acceptable sources of allergy information include individual/carer/parent/guardian or National Care Record.
Exclusions & Additional Prescribing Details Links
  • Criteria for exclusion
  • Cautions including any relevant action to be taken
  • Specific information for suspected infection to be provided
  • Action to be taken if the individual is excluded
  • Action to be taken if the individual/carer/parent/guardian declines treatment
  • Arrangements for referral for medical advice: Refer to the appropriate medical practitioner in the care pathway.
Description of treatment
  • Name, strength & formulation of drug
    • Clarithromycin 250mg tablets
    • Clarithromycin 500mg tablets
    • Clarithromycin 125mg/5mL oral suspension (or oral solution) x 70mL
    • Clarithromycin 250mg/5mL oral suspension (or oral solution) x 70mL
  • Legal category
    • POM
  • Route / method of administration
    • Orally, with water (taken with or without food). Tablets should be swallowed whole.
    • Note: Clarithromycin oral suspension (or oral solution) can cause a bitter after-taste. This can be avoided by drinking juice or water soon after intake of the oral suspension (or oral solution).
  • Off-label use
  • Dose and frequency of administration
    • Children 1–11 years:
      Body-weight:
      • up to 8 kg: 7.5 mg/kg twice daily (every 12 hours)
      • 8–11 kg: 62.5 mg twice daily (every 12 hours)
      • 12–19 kg: 125 mg twice daily (every 12 hours)
      • 20–29 kg: 187.5 mg twice daily (every 12 hours)
      • 30–40 kg: 250 mg twice daily (every 12 hours)
    • Children 12–17 years and adults:
      • 500mg twice daily (every 12 hours)
  • Duration of treatment
    • 5 days
    • Treatment should be started immediately and 5 days of treatment completed.
  • Quantity to be supplied
  • Storage
  • Drug interactions
  • Identification & management of adverse reactions
  • Management of and reporting procedure for adverse reactions
  • Written information to be given to individual/carer/parent/guardian
  • Individual advice / follow up treatment
  • Records
Erythromycin
Erythromycin
Clinical condition or situation to which this PGD applies

Acute otitis media in young people aged 16 or 17 years of age who are pregnant or where pregnancy is suspected and where amoxicillin is not appropriate due to hypersensitivity.

Criteria for inclusion
  • Informed consent
  • Individuals aged 16 or 17 years of age with acute otitis media and otorrhea (discharge after eardrum perforation)
  • Signs and symptoms of acute otitis media using the appropriate NICE CKS guidance:
    • In older children: earache
    AND (on otoscopic examination):
    • Perforation of the tympanic membrane and/or sticky discharge in the external auditory canal.
  • Pregnancy or suspected pregnancy
  • Known hypersensitivity to amoxicillin, any penicillin or any of the components within the formulation of amoxicillin - see Summary of Product Characteristics. Acceptable sources of allergy information include individual/carer/parent/guardian or National Care Record.
    OR
  • History of severe immediate hypersensitivity reaction (e.g. anaphylaxis) to another beta-lactam antibiotic (e.g. cephalosporin, carbapenem or monobactam). Acceptable sources of allergy information include individual/carer/parent/guardian or National Care Record.
Exclusions & Additional Prescribing Details Links
  • Criteria for exclusion
  • Cautions including any relevant action to be taken
  • Specific information for suspected infection to be provided
  • Action to be taken if the individual is excluded
  • Action to be taken if the individual/carer/parent/guardian declines treatment
  • Arrangements for referral for medical advice: Refer to the appropriate medical practitioner in the care pathway.
Description of treatment
  • Name, strength & formulation of drug
    • Erythromycin 250mg tablets
    • Erythromycin 250mg gastro-resistant tablets
    • Erythromycin 500mg tablets
    • Erythromycin 125mg/5mL oral suspension (or oral solution) x 100mL
    • Erythromycin 125mg/5mL sugar free oral suspension (or oral solution) x 100mL
    • Erythromycin 250mg/5mL oral suspension (or oral solution) x 100mL
    • Erythromycin 250mg/5mL sugar free oral suspension (or oral solution) x 100mL
    • Erythromycin 500mg/5mL oral suspension (or oral solution) x 100mL
    • Erythromycin 500mg/5mL sugar free oral suspension (or oral solution) x 100mL
  • Legal category
    • POM
  • Route / method of administration
    • Orally, with water (just before or with food).
    • Tablets should be swallowed whole.
  • Off-label use
  • Dose and frequency of administration
    • Young people and adults aged 16 years and over:
      • 500mg four times daily
  • Duration of treatment
    • 5 days
    • Treatment should be started immediately and 5 days of treatment completed.
  • Quantity to be supplied
  • Storage
  • Drug interactions
  • Identification & management of adverse reactions
  • Management of and reporting procedure for adverse reactions
  • Written information to be given to individual/carer/parent/guardian
  • Individual advice / follow up treatment
  • Records
Key references

Key references

  • Otigo®
  • Amoxicillin
  • Clarithromycin
  • Erythromycin

Exclude: recurrent acute otitis media (3 or more episodes in 6 months or four or more episodes in 12 months), pregnant individuals under 16 years
Exclude: recurrent acute otitis media (3 or more episodes in 6 months or four or more episodes in 12 months), pregnant...
NHSE PATHWAY
NHSE PATHWAY
Acute Otitis Media
Acute Otitis Media
(For children aged 1 to 17 years)
(For children aged 1 to 17 years)
 FOR ALL PATIENTS: If symptoms worsen rapidly or significantly, or the child or young person becomes very unwell OR does not improve despite antibiotics taken for at least 2-3 days
FOR ALL PATIENTS: If symptoms worsen rapidly or significantly, or...
Onward referral
• General practice
• Other provider as appropriate
Onward referral...
Complications or high risk?
Complications or...
Gateway Point
Gateway Point
YES
YES
NO
NO
YES
YES
NO
NO
YES
YES
NO
NO
Offer Erythromycin for 5 days
(subject to inclusion / exclusion criteria in PGD)
plus self care
Offer Erythromycin for 5 days...
if pregnant (aged 16-17 years)
if pregnant (aged 16-17 years)
Acute otitis media more likely
Acute otitis media more likely
NO
NO
YES
YES
NO
NO
YES
YES

Acute otitis media less likely
Acute otitis media less likely





NO
NO
YES
YES
NO
NO
YES
YES

Content sourced and adapted from NHS Pharmacy First – Clinical Pathways and Patient Group Directions (PGDs) on the NHS England website, licensed under the Open Government Licence v3.0.

Content sourced and adapted from NHS Pharmacy First – Clinical Pa...
AND             does the patient have on otoscopic examination:      
AND             does the patient have on otoscopic examina...
Does the patient have acute onset of symptoms including:
Does the patient have acute onset of symptoms including:
1
1
2
2
Patients presenting with signs and symptoms of acute otitis media
Patients presenting with signs and symptoms of acute otitis med...
15
15
Consider the risk of deterioration or serious illness
Consider the risk of deterioration or serious illne...
Consider calculating NEWS2 Score ahead of signposting patient to A&E or calling 999 in a life threatening emergency
Consider calculating NEWS2 Scor...
☐ In older children — earache
☐ In younger children — holding, tugging, or rubbing of the ear
☐ In younger children: non-specific symptoms such as fever, crying, poor feeding, restlessness, behavioural changes, cough, or rhinorrhoea
☐ In older children — earache...
☐ A distinctly red, yellow, or cloudy tympanic membrane
☐ Moderate to severe bulging of the tympanic membrane, with loss of normal landmarks and an airfluid level behind the tympanic membrane
☐ Perforation of the tympanic membrane and/or sticky discharge in the external auditory canal
☐ A distinctly red, yellow, or cloudy tympanic membra...
Does the child/young person have otorrhoea (discharge after eardrum perforation) or eardrum perforation (suspected or confirmed)
Does the child/young person have otorrhoea (discharge after eardrum perforation) or eardrum per...
Onward referral
• General practice
• Other provider as appropriate
Onward referral...
Does the patient meet ANY of the following criteria: 
☐ Patient is systemically very unwell 
☐ Patient has signs of a more serious illness
☐ Patient is high risk of complications because of pre-existing comorbidity (this includes children with  significant heart, lung, renal, liver or neuromuscular disease, immunosuppression, cystic fibrosis  and young children  who were born prematurely)
Does the patient meet ANY of the following criteria:...
Offer self care and pain relief to all patients
Offer self care and pain relief to all pa...
Consider alternative diagnosis and proceed appropriately
Consider alternative diagnosis and proceed a...
Is the child under 2 years AND with infection in both ears?
Is the child under 2 years AND with infection in both ears?
In patients with mild symptoms offer self-care and pain relief
In patients with mild symptom...
Shared decision making approach
and clinician global impression 
Shared decision making approach...
Does the patient meet ANY of the following criteria: 
☐ Severe symptoms based on clinician global impression 
☐ Symptoms for >3 days 
Does the patient meet ANY of the following criteria:...
In patients with moderate and severe symptoms, without eardrum perforation - consider offering phenazone 40 mg/g with lidocaine 10 mg/g ear drops for up to 7 days 
(subject to inclusion/exclusion criteria in PGD) plus self care
In patients with moderate and...
Reported penicillin allergy
(via National Care Record or Patient/Carer)
Reported penicillin allergy...
Ask patient to return to Community Pharmacy if no improvement within 3-5 days for pharmacist reassessment 
Ask patient to return to Commun...
Offer Amoxicillin (if no allergy) for 5 days (subject to inclusion / exclusion criteria in PGD)
plus self care
Offer Amoxicillin (if no allergy) for 5 days (s...
Offer Clarithromycin for 5 days
(subject to inclusion / exclusion criteria in PGD)
plus self care
Offer Clarithromycin for 5 days...
Offer Erythromycin for 5 days
(subject to inclusion / exclusion criteria in PGD)
plus self care
Offer Erythromycin for 5 days...
 FOR ALL PATIENTS: If symptoms worsen rapidly or significantly, or the child or young person becomes very unwell OR does not improve despite antibiotics taken for at least 2-3 days
FOR ALL PATIENTS: If symptoms worsen rapidly or significantly, or...
Onward referral
• General practice
• Other provider as appropriate
Onward referral...
FOR ALL PATIENTS: share self-care and safety-netting, and evidence on antibiotics using NICE guidelines
FOR ALL PATIENTS: share self-care and safety-netting, and evidence on antibiotics using NICE guideli...
Acute otitis media mainly affects children, can last for around 1 week and over 80% of children recover spontaneously without antibiotics 2-3 days from presentation
Acute otitis media mainly affects children, can last for around 1 week and over 80% of children recover spo...Text is not SVG - cannot display
3 Serious illness info
Suspected acute complications:
☐ Meningitis (neck stiffness, photophobia, mottled skin)
☐ Mastoiditis (pain, soreness, swelling, tenderness behind the affected ear(s))
☐ Brain abscess (severe headache, confusion or irritability, muscle weakness)
☐ Sinus thrombosis (headache behind or around the eyes)
☐ Facial nerve paralysis
Suspected acute complications:...
Suspected acute complications:
☐ Meningitis (neck stiffness, photophobia, mottled skin)
☐ Mastoiditis (pain, soreness, swelling, tenderness behind the affected ear(s))
☐ Brain abscess (severe headache, confusion or irritability, muscle weakness)
☐ Sinus thrombosis (headache behind or around the eyes)
☐ Facial nerve paralysis
Suspected acute complications:...
Consider calculating NEWS2 Score ahead of signposting patient to A&E or calling 999 in a life threatening emergency
Consider calculating NEWS2 Scor...Text is not SVG - cannot display
5 Y/N toggle High risk
NO
NO
AND             does the patient have on otoscopic examination:      
AND             does the patient have on otoscopic examina...
Does the patient have acute onset of symptoms including:
Does the patient have acute onset of symptoms including:
1
1
2
2
☐ In older children — earache
☐ In younger children — holding, tugging, or rubbing of the ear
☐ In younger children: non-specific symptoms such as fever, crying, poor feeding, restlessness, behavioural changes, cough, or rhinorrhoea
☐ In older children — earache...
☐ A distinctly red, yellow, or cloudy tympanic membrane
☐ Moderate to severe bulging of the tympanic membrane, with loss of normal landmarks and an airfluid level behind the tympanic membrane
☐ Perforation of the tympanic membrane and/or sticky discharge in the external auditory canal
☐ A distinctly red, yellow, or cloudy tympanic membra...Text is not SVG - cannot display

YES
YES
Consider calculating NEWS2 Score ahead of signposting patient to A&E or calling 999 in a life threatening emergency
Consider calculating NEWS2 Scor...Text is not SVG - cannot display
Hidden
8 Admit
Hidden
10 More clinical features
12 Y/N toggle
NO
NO
Acute otitis media less likely
Acute otitis media less likely
Consider alternative diagnosis and proceed appropriately
Consider alternative diagnosis and proceed a...Text is not SVG - cannot display
Acute otitis media more likely
Acute otitis media more likely
YES
YES

Does the patient meet ANY of the following criteria: 
☐ Patient is systemically very unwell 
☐ Patient has signs of a more serious illness
☐ Patient is high risk of complications because of pre-existing comorbidity (this includes children with  significant heart, lung, renal, liver or neuromuscular disease, immunosuppression, cystic fibrosis  and young children  who were born prematurely)
Does the patient meet ANY of the following criteria:...
Offer self care and pain relief to all patients
Offer self care and pain relief to all pa...Text is not SVG - cannot display
15 Y/N toggle
NO
NO
Does the child/young person have otorrhoea (discharge after eardrum perforation) or eardrum perforation (suspected or confirmed)
Does the child/young person have otorrhoea (discharge after eardrum perforation) or eardrum per...Text is not SVG - cannot display
YES
YES
Onward referral
• General practice
• Other provider as appropriate
Onward referral...Text is not SVG - cannot display
18 Y/N toggle
NO
NO
Is the child under 2 years AND with infection in both ears?
Is the child under 2 years AND with infection in both ears? Text is not SVG - cannot display
YES
YES
Reported penicillin allergy
(via National Care Record or Patient/Carer)
Reported penicillin allergy...Text is not SVG - cannot display
21 Y/N toggle
NO
NO


In patients with mild symptoms offer self-care and pain relief
In patients with mild symptom...
In patients with moderate and severe symptoms, without eardrum perforation - consider offering phenazone 40 mg/g with lidocaine 10 mg/g ear drops for up to 7 days 
(subject to inclusion/exclusion criteria in PGD) plus self care
In patients with moderate and...
Ask patient to return to Community Pharmacy if no improvement within 3-5 days for pharmacist reassessment 
Ask patient to return to Commun...Text is not SVG - cannot display
YES
YES

Shared decision making approach
and clinician global impression 
Shared decision making approach...
Does the patient meet ANY of the following criteria: 
☐ Severe symptoms based on clinician global impression 
☐ Symptoms for >3 days 
Does the patient meet ANY of the following criteria:...Text is not SVG - cannot display
24 Y/N toggle

NO
NO
In patients with moderate and severe symptoms, without eardrum perforation - consider offering phenazone 40 mg/g with lidocaine 10 mg/g ear drops for up to 7 days 
(subject to inclusion/exclusion criteria in PGD) plus self care
In patients with moderate and...
Ask patient to return to Community Pharmacy if no improvement within 3-5 days for pharmacist reassessment 
Ask patient to return to Commun...Text is not SVG - cannot display
YES
YES
Reported penicillin allergy
(via National Care Record or Patient/Carer)
Reported penicillin allergy...Text is not SVG - cannot display
27 Y/N toggle
 FOR ALL PATIENTS: If symptoms worsen rapidly or significantly, or the child or young person becomes very unwell OR does not improve despite antibiotics taken for at least 2-3 days
FOR ALL PATIENTS: If symptoms worsen rapidly or significantly, or...
Onward referral
• General practice
• Other provider as appropriate
Onward referral...
Offer Amoxicillin (if no allergy) for 5 days (subject to inclusion / exclusion criteria in PGD)
plus self care
Offer Amoxicillin (if no allergy) for 5 days (s...
 FOR ALL PATIENTS: If symptoms worsen rapidly or significantly, or the child or young person becomes very unwell OR does not improve despite antibiotics taken for at least 2-3 days
FOR ALL PATIENTS: If symptoms worsen rapidly or significantly, or...
Onward referral
• General practice
• Other provider as appropriate
Onward referral...
NO
NOText is not SVG - cannot display
 FOR ALL PATIENTS: If symptoms worsen rapidly or significantly, or the child or young person becomes very unwell OR does not improve despite antibiotics taken for at least 2-3 days
FOR ALL PATIENTS: If symptoms worsen rapidly or significantly, or...
Onward referral
• General practice
• Other provider as appropriate
Onward referral...
YES
YES
Offer Erythromycin for 5 days
(subject to inclusion / exclusion criteria in PGD)
plus self care
Offer Erythromycin for 5 days...
if pregnant (aged 16-17 years)
if pregnant (aged 16-17 years)
Offer Clarithromycin for 5 days
(subject to inclusion / exclusion criteria in PGD)
plus self care
Offer Clarithromycin for 5 days...
Offer Erythromycin for 5 days
(subject to inclusion / exclusion criteria in PGD)
plus self care
Offer Erythromycin for 5 days...
 FOR ALL PATIENTS: If symptoms worsen rapidly or significantly, or the child or young person becomes very unwell OR does not improve despite antibiotics taken for at least 2-3 days
FOR ALL PATIENTS: If symptoms worsen rapidly or significantly, or...
Onward referral
• General practice
• Other provider as appropriate
Onward referral...Text is not SVG - cannot display
27 + Gateway
31 - Gateway