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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.

Hydrogen peroxide 1% cream
Hydrogen peroxide 1% (10mg/1g) cream
Clinical condition or situation to which this PGD applies

Localised non-bullous impetigo in children over 1 year and adults who are systemically well and not at high risk of complications.

Criteria for inclusion
  • Informed consent
  • Individuals aged 1 year and over
  • Signs and symptoms of impetigo using the appropriate diagnostic (NICE CKS) guidance.
  • Localised (3 or fewer lesions/clusters present) non-bullous impetigo
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
    • Hydrogen peroxide 1% (10mg/1g) cream (e.g. Crystacide® 1% cream)
  • Legal category
    • P
  • Route / method of administration
    • Topical (cutaneous application) to the affected area(s) of the skin.
  • Dose and frequency of administration
    • Children 1 year and over and adults:
    • Apply a thin layer to the affected area(s) up to 3 times a day
    • Use enough of the cream to cover the lesion(s) with a thin layer of cream.
    • A dry film will appear on the skin after each application, this can be washed off with water. Hands should be washed after this also.
  • 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
Fusidic acid 2% cream
Fusidic acid 20mg/g (2%) cream
Clinical condition or situation to which this PGD applies

Localised non-bullous impetigo in children over 1 year and adults who are systemically well and not at high risk of complications.

Criteria for inclusion
  • Informed consent
  • Individuals aged 1 year and over
  • Signs and symptoms of impetigo using the appropriate diagnostic (NICE CKS) guidance.
  • Localised (3 or fewer lesions/clusters present) non-bullous impetigo
  • AND Hydrogen peroxide 1% cream is:
    • Unsuitable (e.g., impetigo around the eye(s)) OR
    • Ineffective (and impetigo remains localised)
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
    • Fusidic acid 20mg/g (2%) cream
  • Legal category
    • POM
  • Route / method of administration
    • Topical (cutaneous application) to the affected area(s) of the skin.
  • Off-label use
  • Dose and frequency of administration
    • Children 1 year and over and adults:
    • Apply a thin layer to the affected area(s) three times daily.
    • Use enough of the cream to cover the lesion(s) with a thin layer of cream.
  • 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
Flucloxacillin
Flucloxacillin
Clinical condition or situation to which this PGD applies

Widespread non-bullous impetigo in children aged 1 year and over and adults who are systemically well and not at high risk of complications.

Criteria for inclusion
  • Informed consent
  • Individuals aged 1 year and over
  • Signs and symptoms of impetigo using the appropriate diagnostic (NICE CKS) guidance.
  • Widespread (4 or more lesions/clusters present) non-bullous impetigo.
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
    • Flucloxacillin 250mg capsules
    • Flucloxacillin 500mg capsules
    • Flucloxacillin 125mg/5mL oral solution (or oral suspension) x 100mL
    • Flucloxacillin 125mg/5mL sugar free oral solution (or oral suspension) x 100mL
    • Flucloxacillin 250mg/5mL oral solution (or oral suspension) x 100mL
    • Flucloxacillin 250mg/5mL sugar free oral solution (or oral suspension) x 100mL
  • Legal category
    • POM
  • Route / method of administration
    • Orally 1 hour before or 2 hours after food. Capsules should be swallowed whole.
    • Note: Flucloxacillin sugar free oral solution (or oral suspension) may have a poor taste potentially leading to reduced compliance. After discussion with individual/carer/parent/guardian consider sugar containing preparation.
    • Children should be encouraged (where possible) to swallow solid oral dose forms (i.e. tablets or capsules):
      • Medicines for Children: has useful guides on how to give medicines, including giving tablets and giving capsules.
      • KidzMed is an eLfH resource for healthcare professionals teaching children to swallow pills.
  • Off-label use
  • Dose and frequency of administration
    • Children aged 1 and over and under 2 years of age:
      • 125 mg four times a day
    • Children 2–9 years:
      • 250 mg four times a day
    • Children 10–17 years and adults:
      • 500 mg four times a day
  • 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

Widespread non-bullous impetigo in children aged 1 year and over and adults, where flucloxacillin is not appropriate due to hypersensitivity.

Criteria for inclusion
  • Informed consent
  • Individuals aged 1 year and over
  • Signs and symptoms of impetigo using the appropriate diagnostic (NICE CKS) guidance.
  • Widespread (4 or more lesions/clusters present) non-bullous impetigo.
  • Known hypersensitivity to flucloxacillin, any penicillin or any of the components within the formulation of flucloxacillin formulations - 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 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, tablets swallowed whole with water (taken with or without food).
    • 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:
      • 250mg 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
  • Additional facilities and supplies
  • 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

Widespread non-bullous impetigo in young people and adults aged 16 years and over who are pregnant, or where pregnancy is suspected and where flucloxacillin is not appropriate due to hypersensitivity.

Criteria for inclusion
  • Informed consent
  • Individuals aged 16 years and over
  • Signs and symptoms of impetigo using the appropriate diagnostic (NICE CKS) guidance.
  • Widespread (4 or more lesions/clusters present) non-bullous impetigo.
  • Known hypersensitivity to flucloxacillin, any penicillin or any of the components within the formulation of flucloxacillin formulations - 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

  • Hydrogen Peroxide
  • Fusidic acid
  • Flucloxacillin
  • Clarithromycin
  • Erythromycin
Complications or high risk?
Complications o...
YES
YES
NO
NO
NHSE PATHWAY
NHSE PATHWAY
Impetigo
Impetigo
(Non-bullous impetigo, for adults and children aged 1 year and over)
(Non-bullous impetigo, for adults and children aged 1 year and over)
Exclude: bullous impetigo, recurrent impetigo (defined as 2 or more episodes in the same year), pregnant individuals under 16 years
Exclude: bullous impetigo, recurrent impetigo (defined as 2 or more episodes in the same year), pregnant individuals u...
Confirm the diagnosis of impetigo through visual examination
Confirm the diagnosis of impetigo through visual examina...
Typical Impetigo?
Typical Impetigo?
YES
YES
NO
NO
YES
YES
NO
NO


if pregnant
if pregnant

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...
Confirm the diagnosis of impetigo through visual examination
Confirm the diagnosis of impetigo through visual examination
15
15
Consider the risk of deterioration or serious illness
Consider the risk of deterioration or serious illne...
YES
YES
NO
NO
FOR ALL PATIENTS: share self-care and safety-netting advice using British Association of Dermatologists Impetigo leaflet
FOR ALL PATIENTS: share self-care and safety-netting advice using British Association of Dermatologists Impetigo le...
Onward referral
• General practice
• Other provider as appropriate
Onward referral...
Impetigo less likely
Impetigo less likely
Consider alternative diagnosis
and proceed appropriately 
Consider alternative diagnos...
Impetigo more likely
Impetigo more likely
Gateway Point
Gateway Point
Does the patient have ≤ 3
lesions/clusters present?
Does the patient have ≤ 3...
Does the patient follow typical progression of
impetigo clinical features?
Does the patient follow typical progression of...
Consider calculating NEWS2 Score ahead of signposting patient to A&E or calling 999 in a life threatening emergency
Consider calculating NEWS2 Scor...
Widespread non-bullous impetigo
Widespread non-bullous impetigo
Does the patient have ≥ 4 lesions/clusters present?
Does the patient have ≥ 4 lesions/clusters present?...
YES
YES
Reported penicillin allergy
(via National Care Record or Patient/Carer)
Reported penicillin allergy...
or if unsuitable or ineffective
or if unsuitable or ineffective
Localised non-bullous impetigo
Localised non-bullous impetigo
FOR ALL PATIENTS:
☐ Offer advice on importance of good hygiene to reduce spread of impetigo
☐ Offer advice on how to take their medicines to encourage adherence 
FOR ALL PATIENTS:...
Offer Hydrogen peroxide 1% cream for 5 days (subject to inclusion / exclusion criteria in protocol)
plus self care
Offer Hydrogen peroxide 1% cream for 5 days (su...
If symptoms worsen rapidly or significantly at any time,
OR do not improve after completion of 7 days treatment course
If symptoms worsen rapidly or significantly at any time,...
Offer Fusidic acid cream for 5 days
(subject to inclusion / exclusion criteria in PGD)
plus self care
Offer Fusidic acid cream for 5 days...
Fusidic acid cream can be offered
2nd line if: 

☐ Hydrogen peroxide unsuitable,
for example if impetigo is around eyes 
☐ Hydrogen peroxide treatment
has been ineffective and impetigo still remains localised
Fusidic acid cream can be offer...
Offer Flucloxacillin (if no allergy) for 5 days (subject to inclusion / exclusion criteria in PGD)
plus self care
Offer Flucloxacillin (if no allergy) for 5 day...
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...Text is not SVG - cannot display
3 Serious illness info
Severe complications suspected (such as deeper soft  tissue infection)
Severe complications suspected (such as deeper soft  tissue infec...
Patient is immunosuppressed and infection is widespread
Patient is immunosuppressed and infection is widespread
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
Does the patient follow typical progression of
impetigo clinical features?
Does the patient follow typical progression of...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
10 More clinical features
☐ The initial lesion is a very thin-walled vesicle on an erythematous base, which ruptures easily and is seldom observed
☐ The exudate dries to form golden yellow or yellow-brown crusts, which gradually thickens
☐ Lesions can develop anywhere on the body but are most common on exposed skin on the face (the peri-oral and peri-nasal areas), limbs and flexures (such as the axillae)
☐ Satellite lesions may develop following autoinoculation
☐ Usually asymptomatic but may be mildly itchy
☐ Refer to NHS.UK website for images of impetigo
☐ The initial lesion is a very thin-walled vesicle on an erythematous base, which ruptures easily and is seldom obse...Text is not SVG - cannot display
12 Y/N toggle
NO
NO
Impetigo less likely
Impetigo less likely
Consider alternative diagnosis
and proceed appropriately 
Consider alternative diagnos...Text is not SVG - cannot display
YES
YES
Impetigo more likely
Impetigo more likely
Gateway Point
Gateway Point
Does the patient have ≤ 3
lesions/clusters present?
Does the patient have ≤ 3...Text is not SVG - cannot display
15 + Gateway
16 - Gateway
17 Y/N toggle
NO
NO
Widespread non-bullous impetigo
Widespread non-bullous impetigo
YES
YES
Reported penicillin allergy
(via National Care Record or Patient/Carer)
Reported penicillin allergy...
Does the patient have ≥ 4 lesions/clusters present?
Does the patient have ≥ 4 lesions/clusters present?...Text is not SVG - cannot display
YES
YES
or if unsuitable or ineffective
or if unsuitable or ineffective
Localised non-bullous impetigo
Localised non-bullous impetigo


Fusidic acid cream can be offered
2nd line if: 

☐ Hydrogen peroxide unsuitable,
for example if impetigo is around eyes 
☐ Hydrogen peroxide treatment
has been ineffective and impetigo still remains localised
Fusidic acid cream can be offer...
Offer Fusidic acid cream for 5 days
(subject to inclusion / exclusion criteria in PGD)
plus self care
Offer Fusidic acid cream for 5 days...
Offer Hydrogen peroxide 1% cream for 5 days (subject to inclusion / exclusion criteria in protocol)
plus self care
Offer Hydrogen peroxide 1% cream for 5 days (su...
FOR ALL PATIENTS:
☐ Offer advice on importance of good hygiene to reduce spread of impetigo
☐ Offer advice on how to take their medicines to encourage adherence 
FOR ALL PATIENTS:...
If symptoms worsen rapidly or significantly at any time,
OR do not improve after completion of 7 days treatment course
If symptoms worsen rapidly or significantly at any time,...
Onward referral
• General practice
• Other provider as appropriate
Onward referral...Text is not SVG - cannot display
20 Y/N toggle
NO
NO

Onward referral
• General practice
• Other provider as appropriate
Onward referral...
If symptoms worsen rapidly or significantly at any time,
OR do not improve after completion of 7 days treatment course
If symptoms worsen rapidly or significantly at any time,...
Offer Flucloxacillin (if no allergy) for 5 days (subject to inclusion / exclusion criteria in PGD)
plus self care
Offer Flucloxacillin (if no allergy) for 5 day...Text is not SVG - cannot display

If symptoms worsen rapidly or significantly at any time,
OR do not improve after completion of 7 days treatment course
If symptoms worsen rapidly or significantly at any time,...
Onward referral
• General practice
• Other provider as appropriate
Onward referral...
YES
YES

if pregnant
if pregnant
Onward referral
• General practice
• Other provider as appropriate
Onward referral...
If symptoms worsen rapidly or significantly at any time,
OR do not improve after completion of 7 days treatment course
If symptoms worsen rapidly or significantly at any time,...
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...Text is not SVG - cannot display