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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...
Patient presenting with
signs and symptoms of infected insect bite
Patient presenting with...
NHSE PATHWAYS
NHSE PATHWAYS
Consider the risk of deterioration, red flags or serious illness
(consider Lyme disease, cellulitis, etc)
Consider the risk of deterioration, red flags or serious illness...
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:...
YES
YES
NO
NO
NICE CKS
NICE CKS
NHSE PGDs
NHSE PGDs
Insect bites and stings
Insect bites and stings
NHS
NHSView PGD in right panelView PGD in right panel
Digital PGD
 Digital PGD
Gateway Point
Gateway Point
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...
Onward referral
  • General practice
  • Other provider as appropriate
Onward referral...
NO
NO
YES
YES
Infected insect bite more likely
Infected insect bite more likely
Offer flucloxacillin (if no allergy) for 5 days (subject to inclusion/exclusion criteria in PGD) plus self care
Offer flucloxacillin (if no allergy) f...
Reported penicillin allergy
(via National Care Record or Patient/Carer)
Reported penicillin allergy...
If pregnant
 If pregnant
Offer clarithromycin for 5 days (subject to inclusion/exclusion criteria in PGD) plus self care
Offer clarithromycin for 5 days (subj...
Offer erythromycin for 5 days (subject to inclusion/exclusion criteria in PGD) plus self care
Offer erythromycin for 5 days (subjec...
If symptoms worsen rapidly or significantly at any time, OR do not improve after completion of 5 days treatment course
If symptoms worsen rapidly or significantly at any time, OR do not improve after c...

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 Pathways and Patient Group Directions (PGDs) on the NHS England website, licensed under the Open Government Licence v3.0.
Infected Insect Bites (For adults and children aged 1 year and over)
Infected Insect Bites Context: UK Pharmacy First Scheme Infected...
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 reaction to insect bite is likely to be an inflamm...
Consider likelihood of Lyme disease (Tick bites - painless and can go unnoticed). Erythema Migrans rash may be indistinguishable from other insect bites. nice.lyme-disease-rash-images
Consider likelihood of Lyme disease (Tick bites - painless and can go unnoticed). Erythema Migrans rash may be indistinguishable from othe...
...
Consider calculating NEWS2 Score ahead of signposting patient to A&E or calling 999 in a life threatening emergency
Consider calculating NEWS2 Score ahea...
Gateway Point
Gateway Point
Is itch the principal symptom? 
(In the absence of other signs or symptoms of infection)
Is itch the principal symptom?...
YES
YES
Recommend self care, oral antihistamine and/or topical steroids over the counter and safety netting advice
Recommend self care, oral antihist...
NO
NO
YES
YES
Recommend self care, oral antihistamine and/or topical steroids over the counter and safety netting advice
Recommend self care, oral antihistamine and/or t...
  • 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 are common and may last...
Infected insect bite less likely
Infected insect bite less likely
NO
NO
YES
YES
NO
NO
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:...
NO
NO
YES
YES
Recommend self care, oral antihistamine and/or topical steroids over the counter and safety netting advice
Recommend self care, oral antihistamine and/or t...
  • 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 and ask patient to mo...
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
  • General practice
  • Other provider as appropriate
Onward referral...
YES
YES
Onward referral
  • General practice
  • Other provider as appropriate
Onward referral...
NO
NO
Exclude: pregnant individuals under 16 years
Exclude: pregnant individuals under 16 ye...Text is not SVG - cannot display