Shingles
Shingles
Urinary Tract Infection
Urinary Tract Infection
Impetigo
Impetigo
Infected Insect Bites
Infected Insect Bites
Acute Sore Throat
Acute Sore Throat
Acute Sinusitis
Acute Sinusitis
Acute Otitis Media
Acute Otitis Media
Text is not SVG - cannot display

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
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.

Flucloxacillin
Clinical condition or situation to which this PGD applies

Infected insect bite(s) and sting(s) in children aged 1 year and over and adults.

Criteria for inclusion
  • Informed consent
  • Individuals aged 1 year and over
  • Diagnosis of infected insect bite or sting using the appropriate diagnostic (NICE CKS) guidance.
  • Clear evidence of infection that is present or worsening at least 48 hours after the initial bite(s) or sting(s) with 3 or more of the following symptoms:
    • Redness of the skin (erythema may be more difficult to distinguish on darker skin tones)
    • Pain or tenderness to the area
    • Swelling of the skin
    • Skin surrounding the bite(s) or sting(s) feels hot to touch
      AND any of the following:
    • Redness or swelling of the skin surrounding the bite(s) or sting(s) is spreading
    • Evidence of pustular discharge at site of bite(s) or sting(s)
Exclusions & Additional Prescribing Details Links
Description of treatment
Clarithromycin
Clinical condition or situation to which this PGD applies

Infected insect bite(s) and sting(s) 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
  • Diagnosis of infected insect bite or sting using the appropriate diagnostic (NICE CKS) guidance.
  • Clear evidence of infection that is present or worsening at least 48 hours after the initial bite(s) or sting(s) with 3 or more of the following symptoms:
    • Redness of the skin (erythema may be more difficult to distinguish on darker skin tones)
    • Pain or tenderness to the area
    • Swelling of the skin
    • Skin surrounding the bite(s) or sting(s) feels hot to touch
      AND any of the following:
    • Redness or swelling of the skin surrounding the bite(s) or sting(s) is spreading
    • Evidence of pustular discharge at site of bite(s) or sting(s)
  • Known hypersensitivity to flucloxacillin, any penicillin or any of the components within the formulation of flucloxacillin – 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
Description of treatment
Erythromycin
Clinical condition or situation to which this PGD applies

Infected insect bite(s) and sting(s) 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 1 year and over
  • Diagnosis of infected insect bite or sting using the appropriate diagnostic (NICE CKS) guidance.
  • Clear evidence of infection that is present or worsening at least 48 hours after the initial bite(s) or sting(s) with 3 or more of the following symptoms:
    • Redness of the skin (erythema may be more difficult to distinguish on darker skin tones)
    • Pain or tenderness to the area
    • Swelling of the skin
    • Skin surrounding the bite(s) or sting(s) feels hot to touch
      AND any of the following:
    • Redness or swelling of the skin surrounding the bite(s) or sting(s) is spreading
    • Evidence of pustular discharge at site of bite(s) or sting(s)
  • Pregnancy or suspected pregnancy
  • Known hypersensitivity to flucloxacillin, any penicillin or any of the components within the formulation of flucloxacillin – 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
Description of treatment
Key references

Key references

Does the patient have acute onset of ≥3 of the following symptoms of an infected insect bite? 
☐ Redness of skin 
☐ Pain or tenderness to the area 
☐ Swelling of skin 
☐ Skin surrounding the bite feels hot to touch
Does the patient have acute onset of ≥3 of the following symptoms...
Exclude: pregnant individuals under 16 years
Exclude: pregnant individuals under 16 years
NHSE PATHWAY
NHSE PATHWAY
Infected Insect Bites
Infected Insect Bites
(For adults and children aged 1 year and over)
(For adults and children aged 1 year and over)


Complications or high risk?
Complications or...
Infected Insect bite more likely
Infected Insect bite more likely
Gateway Point
Gateway Point
YES
YES
NO
NO
YES
YES
NO
NO
YES
YES
NO
NO
Infected insect bite less likely
Infected insect bite less likely
Reported penicillin allergy
(via National Care Record or Patient/Carer)
Reported penicillin allergy...
NO
NO
YES
YES
NO
NO
YES
YES
NO
NO
YES
YES
NO
NO
YES
YES

NO
NO
YES
YES
Onward referral
• Other provider as appropriate
• General practice
Onward referral...

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...
Do not offer an antibiotic if there are no signs or symptoms of infection. Be aware that a rapid-onset skin reaction to insect bite is likely to be an inflammatory or allergic reaction rather than an infection. Most insect bites and stings are not serious and will get better within a few hours or days, and do not need treatment with antibiotics.
Do not offer an antibiotic if there are no signs or symptoms of infection. Be aware that a rapid-onset skin...
Patient presenting with signs and symptoms of infected insect bite
Patient presenting with signs and symptoms of infected insect b...
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...
Does the patient meet ANY of the following criteria:
☐ Bite or scratch caused by animal(s)
☐ Bite caused by human(s)
☐ Bite caused by tick in the UK and signs of Lyme disease such as erythema migrans (bullseye) rash
☐ Bite or sting that occurred while travelling outside of UK with concern of insect borne diseases e.g. malaria, tick borne encephalitis
☐ Bite or sting caused by an unusual or exotic insect 
Does the patient meet ANY of the following criteria:...
Onward referral
• General practice
• Other provider as appropriate
Onward referral...
Has it been at least 48 hours after the initial insect bite or sting?
Has it been at least 48 hours after the initial insect bite or stin...
Recommend self care, oral antihistamine and/or topical steroids over the counter and safety netting advice
Recommend self care, oral an...
Is itch the principal symptom?
(In the absence of other signs or symptoms of infection)
Is itch the principal symptom?...
Recommend self care, oral antihistamine and/or topical steroids over the counter and safety netting advice
Recommend self care, oral an...
☐ Skin redness and itching are common and may last for up to 10 days
☐ It is unlikely that the skin will become infected
☐ Avoiding scratching may reduce inflammation and the risk of infection
☐ Skin redness and itching ar...
Does the patient meet ANY of the following criteria:
☐ Redness and swelling of skin surrounding the bite is spreading
☐ There is evidence of pustular discharge at site of bite/sting?
Does the patient meet ANY of the following criteria:...
☐ Clearly demarcate the area and ask patient to monitor
☐ Ask patient to return to pharmacy if symptoms worsen at any time OR do not improve after 3 days of over the counter treatment for pharmacist reassessment
☐ Clearly demarcate the area...
Recommend self care, oral antihistamine and/or topical steroids over the counter and safety netting advice
Recommend self care, oral an...
Does the patient meet ANY of the following criteria:
☐ Patient systemically unwell
☐ Known comorbidity which may complicate or delay resolution of infection: for example peripheral arterial disease, chronic venous insufficiency, lymphoedema or morbid obesity
☐ Severe pain out of proportion to the wound (may indicate the presence of toxin-producing bacteria)
☐ Patient has significant collection of fluid or pus at site of infection (for incision and drainage where appropriate) 
Does the patient meet ANY of the following criteria:...
Onward referral
• Other provider as appropriate
• General practice
Onward referral...
Reported penicillin allergy
(via National Care Record or Patient/Carer)
Reported penicillin allergy...

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...
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,...


if pregnant
if pregnant
Offer Erythromycin for 5 days
(subject to inclusion / exclusion criteria in PGD)
plus self care
Offer Erythromycin for 5 days...
Offer Clarithromycin for 5 days
(subject to inclusion / exclusion criteria in PGD)
plus self care
Offer Clarithromycin for 5 days...
Text is not SVG - cannot display
3 Serious illness info
5 Y/N toggle High risk
NO
NO
Does the patient meet ANY of the following criteria:
☐ Bite or scratch caused by animal(s)
☐ Bite caused by human(s)
☐ Bite caused by tick in the UK and signs of Lyme disease such as erythema migrans (bullseye) rash
☐ Bite or sting that occurred while travelling outside of UK with concern of insect borne diseases e.g. malaria, tick borne encephalitis
☐ Bite or sting caused by an unusual or exotic insect 
Does the patient meet ANY of the following criteria:...
Text is not SVG - cannot display
Hidden
10 More clinical features
12 Y/N toggle
NO
NO
Has it been at least 48 hours after the initial insect bite or sting?
Has it been at least 48 hours after the initial insect bite or stin...
Text is not SVG - cannot display
15 Y/N toggle
YES
YES
Is itch the principal symptom?
(In the absence of other signs or symptoms of infection)
Is itch the principal symptom?...
Text is not SVG - cannot display
18 Y/N toggle
NO
NO
Does the patient have acute onset of ≥3 of the following symptoms of an infected insect bite? 
☐ Redness of skin 
☐ Pain or tenderness to the area 
☐ Swelling of skin 
☐ Skin surrounding the bite feels hot to touch
Does the patient have acute onset of ≥3 of the following symptoms...
Text is not SVG - cannot display
21 Y/N toggle
Infected Insect bite more likely
Infected Insect bite more likely
YES
YES
Does the patient meet ANY of the following criteria:
☐ Redness and swelling of skin surrounding the bite is spreading
☐ There is evidence of pustular discharge at site of bite/sting?
Does the patient meet ANY of the following criteria:...
Text is not SVG - cannot display
24 Y/N toggle
YES
YES

Does the patient meet ANY of the following criteria:
☐ Patient systemically unwell
☐ Known comorbidity which may complicate or delay resolution of infection: for example peripheral arterial disease, chronic venous insufficiency, lymphoedema or morbid obesity
☐ Severe pain out of proportion to the wound (may indicate the presence of toxin-producing bacteria)
☐ Patient has significant collection of fluid or pus at site of infection (for incision and drainage where appropriate) 
Does the patient meet ANY of the following criteria:...
Text is not SVG - cannot display
27 + Gateway
29 Y/N toggle
error: <b>Alert: </b>Content selection is disabled!!