Empirical antibiotic guidelines for children

Cellulitis/Impetigo

Cellulitis presents with an acute onset of red, painful, hot, swollen, and tender skin, with possible blister or bullae formation. The leg is the most commonly affected site, presentation is usually unilateral. Often (but not always) associated with a break in the skin (portal entry).

If patient afebrile and tolerating oral antibiotics, can be managed in primary care. Caution with immunocompromised patients.

Most children with cellulitis or impetigo do not require skin swabs sent, unless portal of entry, extensive infection, not responding to treatment or recurrent episodes. If recurrent or severe staph aureus infection, consider requesting PVL testing.

If mild/moderate infection, Cefalexin for 5 days. Dose per actual body weight (12.5mg/kg 8 hourly (max 1g per dose)) or using age bands (3-11 months: 125mg tds, 1 year - 4 years: 250mg tds, 5-11 years: 500mg tds, ≥12 years: 1 gram tds)

If facial cellulitis, Co-amoxiclav tds for 5 days. For child 1 years - 5 years: co-amoxiclav 125/31 5ml tds' 6-11 years: co-amoxiclav 250/62 5ml tds; 12-17 years: co-amoxiclav tablets (500/125 mg) tds or co-amoxiclav 250/62 10ml tds).

If allergic to penicillin: Clarithromycin for 5 days. For children 1 month - 11 years, dose using weight bands (up to 8kg: 7.5mg/kg bd; 8-11kg: 62.5 mg bd; 12-19kg: 125mg bd; 20-29kg: 187.5mg bd; >30kg: 250mg bd). Child 12-17 years, 250mg bd or 500mg m/r od)

Most children with infected eczema do not benefit from antibiotic therapy (oral or topical) - except those with a severe infection. Optimisation of topical steroids is the mainstay of treatment in these patients.

Provide safety netting information (verbal and written).

Not: aim to use an antibiotic that minimises dosing frequency and is palatable (if suspension prescribed) to optimise adherence. QDS penicillin V and flucloxacillin suspensions are not well tolerated by children.

Click here for a link to South Central Antimicrobial Network Guidelines for Antibiotic Prescribing in the Community 2018.

Conjunctivitis

Usually no treatment required; viral cause most likely (adenovirus, enterovirus, occasionally herpes simplex). Consider ophthalmia neonatorum in a neonate; this does not refer to a simple "sticky eye" in a neonate and requires urgent review in hospital

Consider chloramphenicol eye drops and chloramphenicol ointment 1%. Continue until 2 days after symptoms resolved.

Click here for a link to South Central Antimicrobial Network Guidelines for Antibiotic Prescribing in the Community 2018.



Lymphadenitis

If lymphadenopathy is bilateral, non-erythematous, non-tender, with node size less than 3 cm, and child systemically well, consider no treatment, watchful waiting approach. Low threshold for treatment if child immunocompromised.

If mild/moderate infection, Cefalexin for 7 days. Dose per actual body weight (12.5mg/kg 8 hourly (max 1g per dose)) or using age bands (3-11 months: 125mg tds, 1 year - 4 years: 250mg tds, 5-11 years: 500mg; ≥12 years: 1 gram tds)

If allergic to penicillin: Clarithromycin for 7 days. For children 1 month - 11 years, dosing using weight bands (up to 8kg: 7.5mg/kg bd; 8-11kg: 62.5mg bd; 12-19kg: 125mg bd; 20-29kg: 187.5mg bd; >30kg: 250mg bd). Child 12-17 years, 250mg bd or 500mg m/r od




Provide safety netting information (verbal and written).

Note: aim to use an antibiotic that minimises dosing frequency and is palatable (if suspension prescribed) to optimise adherence. QDS penicillin V and flucloxacillin suspensions are not well tolerated by children.

Click here for a link to South Central Antimicrobial Network Guidelines for Antibiotic Prescribing in the Community 2018.

Otitis Externa

Cure rates similar at 7 days for topical acetic acid or Ab +- steroid.

First line: Acetic acid 2% one spray tds for 7 days (unlicensed use)

Second line: Neomycin with corticosteroid ear drops, three drops tds for 7-14 days

If cellulitis and disease extending outside ear canal, start oral antibiotics based on sensitivities. Empirical treatment with Cefalexin for 5 days. Dose per actual body weight (12.5mg/kg 8 hourly (max 1g per dose)) or using age bands (3-11 months: 125mg tds, 1 year-4 years: 250mg tds, 5-11 years: 500mg tds, ≥12 years: 1 gram tds). If allergic to penicillin/cephalosporins: Azithromycin for 3 days. Dose per actual body weight (10mg/kg od) or using weight bands for children aged 6 months - 17 years (15-25kg: 200mg once daily; 26-35kg: 300mg once daily; 36-45kg: 400mg once daily; ≥46kg: 500mg once daily)

Click here for a link to South Central Antimicrobial Network Guidelines for Antibiotic Prescribing in the Community 2018.

Otitis Media

Acute otitis media resolves in 60% by 24 hours without Abs. Abs only marginally reduces pain at 2 days (NNT 15) and does not prevent deafness. Need to treat 4800 with antibiotics to avoid 1 case of mastoiditis.

If ear discharge but systemically well and apyrexial, treat with topical antibiotics (sofradex or neomycin) for 10 days.

Only consider starting oral antibiotics if any of the following criteria are met in a child presenting with AOM (bulging ear drum or discharge):-

  • Symptoms for 4 days or more
  • Purulent discharge from ear canal (not due to otitis externa)
  • Systemically unwell
  • Under 6 months of age with presumed acute OM.

In child 6 months - 2 years old:-

  • bilateral OM
  • unilateral OM and symptom score of >8 (0=no symptoms, 1=a little, 2-a lot) for the following criteria:-
  • fever (>39 degrees = score of 2).
  • tugging ears
  • crying more
  • irritability
  • difficulty sleeping
  • less playful
  • eating less

First line if antibiotics indicated: Amoxicillin bd for 5 days. Dose per actual body weight (40mg/kg bd (max 1g per dose)) or using age bands (3-11 months: 250mg bd; 1 years - 4 years: 500mg bd; 5-11 years: 750mg bd; ≥12 years: 1 gram bd)

If failed treatment with amoxicillin, Co-amoxiclav tds for 5 days. For children 1-5 years: co-amoxiclav 125/31 5 ml tds; 6-11 years: co-amoxiclav 250/62 5 ml tds; 12-17 years: co-amoxiclav tablets (500/125mg) tds or co-amoxiclav 250/62 10 ml tds)

If allergic to penicillin: Azithromycin for 3 days. dose per actual body weight (10mg/kg od) or using weight bands for children aged 6 months - 17 years (15-25kg: 200mg once daily; 26-35kg: 300mg once daily; 36-45kg: 400mg once daily; ≥46kg: 500mg once daily)

Provide safety netting information (verbal and written).

Click here for a link to South Central Antimicrobial Network Guidelines for Antibiotic Prescribing in the Community 2018.

Pneumonia

Most lower respiratory tract infections are of viral aetiology - consider bacterial pneumonia if persistent/recurrent fever over preceding 24-48 hours with chest wall recession and tachypnoea. Presence of generalised wheeze makes viral aetiology far more likely.

First line if antibiotics indicated: Amoxicillin bd for 5 days. Dose per actual body weight (40mg/kg bd (max 1g per dose)) or using age bands (3-11 monthsL 250mg; 1-4 years: 500mg bd; 5-11 years: 750mg ≥12 years: 1 gram bd)

If no response to amoxicillin, Co-amoxiclav for 3 days. Dose per actual body weight (10mg/kg od) or using weight bands for children aged 6 months - 17 years (15-25kg: 200mg once daily; 26-35kg: 300mg once daily; 36-45kg: 400mg once daily; ≥46kg: 500mg once daily)

If allergic to penicillin: Azithromycin for 3 days. Dose per actual body weight (10mg/kg od) or using weight bands for children aged 6 months - 17 years (15-25kg: 200mg once daily; 26-35kg: 300mg once daily; 36-45kg: 400mg once daily; ≥46kg: 500mg once daily

Treatment for atypical infections should only be considered in severe infection if no response to first line empirical therapy: use Azithromycin for 3 days. Dose per actual body weight (10mg/kg od) or using weight bands for children aged 6 months - 17 years (15-25kg: 200mg once daily; 26-35kg: 300mg once daily; 36-45kg: 400mg once daily; ≥46kg: 500mg once daily)


If severe or complicated pneumonia (O² sats<85%, haemodynamic instability/septicaemia, immunocompromised, chronic lung disease, congenital hear disease, empyema, necrotising pneumonia), for urgent review in hospital - call paediatrician.

Treatment for atypical infections should only be considered in sever infection if no response to first line empirical therapy - use azithromycin.

Provide safety netting information (verbal and written).

Note: aim to use an antibiotic that minimises dosing frequency and is palatable (if suspension prescribed) to optimise adherence. QDS penicillin V and flucloxacillin suspensions are not well tolerated by children.

Click here for a link to South Central Antimicrobial Network Guidelines for Antibiotic Prescribing in the Community 2018.

Rhinosinusitis

Generally, Abs are not required as 80% resolve within 14 days without Tx (NNT 15). Offer adequate analgesia.

Consider treating if most of the following are present:

  • Symptoms for more than 10 days
  • Marked deterioration after an initial milder phase
  • Fever
  • Unremitting purulent nasal discharge

First line: if no previous treatment in preceding 4 weeks, Amoxicillin bd for 5 days. Dose per actual body weight (40mg/kg bd (max 1g per dose)) or using age bands (3-11 months: 250mg bd; 1 year - 4 years: 500mg bd; 5-11 years: 750mg bd >12 years: 1 gram bd)

If treatment with amoxicillin in preceding 4 weeks: Co-amoxiclav tds for 5 days. For children 1 years - 5 years: co-amoxiclav 125/31 5 ml tds; 6-11 years: co-amoxiclav 250/62 5 ml tds; 12-17 years: co-amoxiclav tablets (500/125mg) tds or co-amoxiclav 250/62 10 ml tds)

If allergic to penicillin: Azithromycin for 3 days. Dose per actual body weight (10mg/kg od) or using weight bands for children aged 6 months - 17 years (15-25kg: 200mg once daily; 26-35kg: 300mg once daily; 36-45kg: 400mg once daily; ≥46kg: 500mg once daily)

Click here for a link to South Central Antimicrobial Network Guidelines for Antibiotic Prescribing in the Community 2018.

Tonsillitis

Most young children presenting with tonsillitis have a viral aetiology. No significant difference in pain score at day 3 in children treated with antibiotics compared to those treated with placebo (Cochrane review 2013). Need to treat >4000 children with antibiotics to prevent one case of quinsy.

Most children with tonsillitis do not require a throat swab.

Base decision to treat on FeverPAIN score (1 point for each of Fever, Purulence, Attend within 3 days of onset or less, severely Inflamed tonsils, No cough or coryza):

  • score 0-1 = 18% streptococci: use NO antibiotics
  • score 2-3: 34-40% streptococci, use back up/delayed antibiotic
  • score ≤4: 62-65% streptococci, use immediate Ab.
  • Based on Little et al, BMJ 2013

Score validated in children 3 years and over - younger children are less likelyto have a bacterial aetiology and are less likely to develop complications.

For children unable to swallow tablets; amoxicillin 40mg/kg bd (max 1g per dose) for 7 days. Dose per actual body weight (40mg/kg bd (max 1g per dose)) or using age bands (3-11 months: 250mg bd; 1 year - 4 years: 500mg bd; 5-11 years: 750mg bd; >12 years: 1 gram bd) - (2012 Cochrane review). The use of amoxicillin does not significantly increase the risk of rash in acute EBV.

For children able to swallow tablets; if age 6-12 years, penicillin V 500mg 12 hourly; if age >12 years, penicillin V 1g 12 hourly for 7 days.

If allergic to penicillin: Azithromycin for 3 days. Dose per actual body weight (10mg/kg od) or using weight bands for children aged 6 months - 17 years (15-25kg: 200mg once daily; 26-35kg: 300mg once daily; 36-45kg: 400mg once daily; ≥46kg: 500mg once daily)

Provide safety netting information (verbal and written).

Note: aim to use an antibiotic that minimises dosing frequency and is palatable (if suspension prescribed) to optimise adherence. QDS penicillin V and flucloxacillin suspensions are not well tolerated by children.

Click here for a link to South Central Antimicrobial Network Guidelines for Antibiotic Prescribing in the Community 2018.

Urinary Tract Infection

<3 months of age:

Treat as pyelonephritis (needs review in hospital - call paediatrician .

>3 months of age with lower UTI/cystitis:

Trimethoprim bd for 3 days. Dose per actual body weight (4mg/kg bd (max 200mg/dose) or using age bands (6 weeks - 5 months: 25 mg twice daily; 6 months - 5 years: 50mg twice daily; 6 - 11 years" 100mg twice daily; 12 - 17 years: 200mg twice daily).

If previous treatment with trimethoprim in preceding 3 months use Nitrofurantoin for 3 days if able to swallow tablets (immediate release 750mcg/kg qds or if 12 - 17 years 100mg m/r bd) OR Cefalexin tds for 3 days. Dose per actual body weight (12.5mg/kg 8 hourly (max 1g per dose)) or using age bands (3-11 months: 125mg tds, 1 year - 4 years: 250mg tds, 5-11 years 500mg tds, ≥12 years: 1 gram tds). If confirmed severe penicillin allergy and unable to swallow nitrofurantoin tabletsL Ciprofloxacin 10mg/kg bd (max 750mg bd).

>3 months of age with upper UTI/pyelonephritis (all children with a febrile UTI should be considered to have pyelonephritis):

Duration of antibiotic course 7 days: treat empirically with Cefalexin 12.5mg/kg 8 hourly for 7 days unless unable to tolerate oral antibiotics or systemically unwell (suggestive of bacteraemia). Dose per actual body weight (12.5mg/kg 8 hourly (max 1g per dose)) or using age bands (3-11 months: 125mg tds, 1 year - 4 years: 250mg tds, 5-11 years: 500mg tds, ≥12 years: 1 gram tds). It confirmed severe penicillin allergy: Ciprofloxacin 10mg/kg bd (max 750mg bd).

If unable to tolerate oral Abs or systemically unwell (suggestive of bacteraemia), requires review in hospital for consideration of IV antibiotics - call paediatrician.

Provide safety netting information (verbal and written)

QuickWee method of stimulating suprapubic area with saline-soaked gauze significantly reduces the time taken to successfully collect a urine sample in infants.



Click here for a link to South Central Antimicrobial Network Guidelines for Antibiotic Prescribing in the Community 2018.

Hide this section
Show accessibility tools