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 25mg/kg 8 hourly (max 1g per dose). Co-amoxiclav if facial cellulitis.

Use clarithromycin if confirmed penicillin allergy. Duration of antibiotic course 5 days.

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.

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.

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, cefalexin 25mg/kg 8 hourly (max 1g per dose) or co-amoxiclav

Duration of antibiotic course 7 days

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.

Otitis Externa

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

First line: acetic acid

Second line: neomycin with corticosteroid

If cellulitis and disease extending outside ear canal, start oral Abs based on sensitivities. Empirical treatment with cefalexin 25mg/kg 8 hourly (max 1g per dose) or co-amoxiclav.

Use azithromycin for 3 days if confirmed penicillin allergy.

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

Treat with amoxicillin 40mg/kg 12 hourly (max 1g per dose) 12 hourly for 5 days.

If failed treatment with amoxicillin, co-amoxiclav for 5 days

Use azithromycin for 3 days if confirmed penicillin allergy

Provide safety netting information (verbal and written).

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.

Amoxicillin 40mg/kg bd (max 1g per dose) 12 hourly (or co amoxiclav if no response to amoxicillin). Duration of antibiotic course 5 days. Use azithromycin for 3 days if confirmed penicillin allergy.

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.

Rhinosinusitis

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

Treat if worsening upper respiratory tract symptoms (fever, daytime cough or nasal discharge) following resolution of viral UTI, severe symptoms (fever >39 degrees, purulent nasal discharge) or persistent symptoms (nasal discharge or daytime cough >10 days).

Amoxicillin 40mg/kg 12 hourly (max 1g per dose) if no previous treatment in preceding 4 weeks. If treatment with amoxicillin in preceding 4 weeks, co-amoxiclav. Duration of treatment 7 days after improvement in symptoms (usually 10-14 days)

Use azithromycin for 3 days if confirmed penicillin allergy.

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 12 hourly (max 1g per dose) for 7 days (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.

Use azithromycin for 5 days if confirmed penicillin allergy.

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.

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 4mg/kg 12 hourly (max 200mg/dose).

If previous treatment with trimethoprim in preceding 3 months, use nitrofurantoin (if able to swallow tablets) or cefalexin 25mg/kg 8 hourly (max 1 gram/dose). If confirmed severe penicillin allergy and unable to swallow nitofurantoin tablets, for ciprofloxacin.

Duration of antibiotic course 3 days.

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

Treat empirically with cefalexin 25mg/kg 8 hourly (max 1 gram/dose) unless unable to tolerate oral Abs or systemically unwell (suggestive of bacteraemia).

Ciprofloxacin if confirmed severe penicillin allergy.

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.



Hide this section
Show accessibility tools