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 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.

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.

For limited non-bullous impetigo, use a topical antiseptic, such as hydrogen peroxide 1% cream applied 2 to 3 times a day for 5-7 days

or

topical Abs (fusidic acid 2% cream or mupirocin 2% ointment) tds for 5-7 days.

Cefalexin for 5-7 days. 12.5mg/kg bd (max 1g per dose) or 1-11 months: 125mg bd. 1 year - 4 years: 125mg tds. 5-11 years: 250mg tds. 12 years and over: 500mg bd-tds.

or

Flucloxacillin for 5-7 days. 1-23 months: 62.5-125mg qds. 2-9 years: 125-250mg qds. 10-17 years: 250-500mg qds.

If facial cellulitis, Co-amoxiclav for 5-7 days. 1-11 months: 0.25 mL/kg of 125/31 co-amoxiclav liquid tds. 1-5 years: co-amoxiclav 125/31 liquid 5mL tds. 6-11 years co-amoxiclav 250/62 liquid 5mL tds. 12-17 years co-amoxiclav 250/62 liquid 10mL tds.

If allergic to penicillin: Clarithromycin for 5-7 days. Dose: Under 8kg: 7.5 mg/kg bd. 8 to 11kg: 62.5 mg bd. 12 to 19kg: 125 mg bd. 20 to 29kg: 187.5 mg bd. 30 to 40kg: 250mg bd. 12 to 17 years: co-amoxiclav tablets (500/125mg) 1 tds or co-amoxiclav 250/62 liquid 10 mL tds.

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).

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. It can sometimes be challenging for children to swallow large volumes of suspensions. Most school age children (from above 4 years of age) can be taught to swallow tablets. The following website provides great information for parents on teaching their child to swallow tables - www.pillswallowing.com

References

1. BNF-C accessed at https://bnfc.nice.org.uk in August 2019.

2. NICE (2019). Cellulitis and erysipelas: antimicrobial prescribing.

3. Dillon HC Jr. Treatment of staphylococcal skin infections: a comparison of cephalexin and dicloxacillin. J Am Acad Dermatol. 1983 Feb;8(2):177-81.

4. Aboltins CA et al. Oral versus parenteral antimicrobials for the treatment of cellulitis: a randomized non-inferiority trial. J Antimicrob Chemother. 2015 Feb;70(2):581-6.

5. Baguley D, Lim E, Bevan A, Pallet A and Faust SN. Prescribing for children – taste and palatability affect adherence to antibiotics: a review Archives of Disease in Childhood 2012;97:293-297

6. Falagas ME, Karagiannis AKA, Nakouti T, Tansarli GS. Compliance with Once-Daily versus Twice or Thrice-Daily Administration of Antibiotic Regimens: A Meta-Analysis of Randomized Controlled Trials. PLoS ONE. 2015;10(1):e0116207. doi:10.1371/journal.pone.0116207.

7. Bielicki JA, Barker CI, Saxena S, Wong IC, Long PF, Sharland M. Not too little, not too much: problems of selecting oral antibiotic dose for children. BMJ. 2015 Nov 3;351:h5447.

8. Malhotra-Kumar S, Lammens C, Coenen S, Van Herck K, Goossens H. Effect of azithromycin and clarithromycin therapy on pharyngeal carriage of macrolide-resistant streptococci in healthy volunteers: a randomised, double-blind, placebo-controlled study. Lancet. 2007 Feb 10;369(9560):482-90.

9. Dancer SJ. Attention prescribers: be careful with antibiotics. Lancet. 2007 Feb 10;369(9560):442-3.

10. Koning S et al. Interventions for impetigo. Cochrane database of systematic reviews 2012.

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

Click here for tips for antibiotic prescribing in children and the rationale for the changes in the 2018 guidelines.

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 0.5% and chloramphenicol ointment 1%. Continue until 2 days after symptoms resolved.

Provide safety netting information (written and verbal)

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

Click here for tips for antibiotic prescribing in children and the rationale for the changes in the 2018 guidelines.


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: 1-11 months: 125mg bd. 1 year-4 years: 125mg tds. 5-11 years: 250mg tds. 12 years and over: 500mg bd-tds

If allergic to penicillin: Clarithromycin for 7 days. Dose: Under 8kg: 7.5mg/kg bd. 8 to 11kg: 62.5,g bd. 12 to 19kg: 125 mg bd. 20 to 29kg: 187.5 mg bd. 30 to 40kg: 250 mg bd. 12 to 17 years: 500mg bd


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. It can sometimes be challenging for children to swallow large volumes of suspensions. Most school age children (from above 4 years of age) can be taught to swallow tablets. The following website provides great information for parents on teaching their child to swallow tables - www.pillswallowing.com

References

1. Baguley D, Lim E, Bevan A, Pallet A and Faust SN. Prescribing for children – taste and palatability affect adherence to antibiotics: a review Archives of Disease in Childhood 2012;97:293-297

2. Bielicki JA, Barker CI, Saxena S, Wong IC, Long PF, Sharland M. Not too little, not too much: problems of selecting oral antibiotic dose for children. BMJ. 2015 Nov 3;351:h5447.

3. Malhotra-Kumar S, Lammens C, Coenen S, Van Herck K, Goossens H. Effect of azithromycin and clarithromycin therapy on pharyngeal carriage of macrolide-resistant streptococci in healthy volunteers: a randomised, double-blind, placebo-controlled study. Lancet. 2007 Feb 10;369(9560):482-90.

4. Dancer SJ. Attention prescribers: be careful with antibiotics. Lancet. 2007 Feb 10;369(9560):442-3.

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

Click here for tips for antibiotic prescribing in children and the rationale for the changes in the 2018 guidelines.

Otitis Externa

Cure rates similar at 7 days for topical acetic acid or topical 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 (off-label) for 5 days. Dose: 12.5mg/kg tds (max 1g per dose), or, 1-11 months: 125mg bd. 1 year-4 years: 125 mg tds. 5-11 years: 250mg tds. 12 years and over: 500mg bd-tds.

Or

Flucloxacillin for 5 days. Dose: 1 month to 1 year: 62.5mg-125mg qds. 2-9 years: 125mg-250mg qds. 10-17 years: 250mg-500mg qds.

If allergic to penicillin/cephalosporins: Erythromycin for 5 days. Dose: 1-23 months: 250 mg bd. 2-7 years: 500mg bd. 8-17 years: 500mg-1g bd.

Or

Clarithromycin for 5 days. Dose: Under 8kg: 7.5mg/kg bd. 8 to 11kg: 62.5mg bd. 12 to 19kg: 125 mg bd. 20 to 29kg: 187.5 mg bd. 30 to 40kg: 250 mg bd. 12 to 17 years: 500mg bd.

Evidence: Cure rates similar at 7 days for topical acetic acid or antibiotic +/- steroid.

Provide safety netting information (written and verbal)

References

1. Malhotra-Kumar S, Lammens C, Coenen S, Van Herck K, Goossens H. Effect of azithromycin and clarithromycin therapy on pharyngeal carriage of macrolide-resistant streptococci in healthy volunteers: a randomised, double-blind, placebo-controlled study. Lancet. 2007 Feb 10;369(9560):482-90.

2. Dancer SJ. Attention prescribers: be careful with antibiotics. Lancet. 2007 Feb 10;369(9560):442-3.

3. Bielicki JA, Barker CI, Saxena S, Wong IC, Long PF, Sharland M. Not too little, not too much: problems of selecting oral antibiotic dose for children. BMJ. 2015 Nov 3;351:h5447.

4. Baguley D, Lim E, Bevan A, Pallet A and Faust SN. Prescribing for children – taste and palatability affect adherence to antibiotics: a review Archives of Disease in Childhood 2012;97:293-297

5. Falagas ME, Karagiannis AKA, Nakouti T, Tansarli GS. Compliance with Once-Daily versus Twice or Thrice-Daily Administration of Antibiotic Regimens: A Meta-Analysis of Randomized Controlled Trials. PLoS ONE. 2015;10(1):e0116207. doi:10.1371/journal.pone.0116207.

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

Click here for tips for antibiotic prescribing in children and the rationale for the changes in the 2018 guidelines.

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 OR unilateral OM and symptom score of >8 (0=no symptoms, 1=a little, 2-a lot) for the following criteria:-
    • fever (38-38.9 degrees = score of 1; >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)) 12 hourly (off-label) or using age bands (1-11 months: 125 tds or 250mg bd (off-label); 1 years - 4 years: 250mg bd (off-label); 5-11 years: 500mg tds (off-label); ≥12 years: 500mg tds or 1 gram bd (off-label))

If failed treatment with amoxicillin or consider if high risk of complications:

Co-amoxiclav for 5 days. Dose: 1-11 months: 0.25 ml/kg of 125/31 co-amoxiclav liquid tds. 1-5 years: co-amoxiclav 125/31 liquid 5 mL tds. 6-11 years: co-amoxiclav 250/62 liquid 5 mL tds. 12-17 years: co-amoxiclav tablets (500/125mg) 1 tds or co-amoxiclav 250/62 liquid 10 mL tds.

If allergic to penicillin:

Clarithromycin for 5 days. Dose: Under 8kg: 7.5 mg/kg bd. 8 to 11kg: 62.5 mg bd. 12 to 19kg: 125mg bd. 20 to 29kg: 187.5 mg bd. 30 to 40kg: 250 mg bd. 12 to 17 years: 250 mg - 500mg bd.

Or

Erythromycin for 5 days. Dose: 1-23 months: 125mg qds or 250 mg bd. 2-7 years: 250 mg qds or 500 mg bd. 8-17 years: 250 mg - 500mg bd.

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. It can sometimes be challenging for children to swallow large volumes of suspensions. Most school age children (from above 4 years of age) can be taught to swallow tablets. The following website provides great information for parents on teaching their child to swallow tablets - www.pillswallowing.com

References

1. NICE, Otitis media (acute): antimicrobial prescribing [NG91], March 2018 https://www.nice.org.uk/guidance/ng91 Date accessed 25.5.18

2. Hoberman A, Paradise JL, Rockette HE, Shaikh N, Wald ER, Kearney DH, et al. Treatment of acute otitis media in children under 2 years of age. N Engl J Med. 2011; 364(2): 105-15. https://www.ncbi.nlm.nih.gov/pubmed/21226576 Date accessed 25.5.18

3. Thompson PL, Gilbert RE, Long PF, Saxena S, Sharland M, Wong IC. Effect of antibiotics for otitis media on mastoiditis in children: a retrospective cohort study using the United kingdom general practice research database. Pediatrics. 2009; 123(2): 424-30. https://www.ncbi.nlm.nih.gov/pubmed/19171605 Date accessed 25.5.18

4. Valtonen M, Piippo T, Pitkäjärvi T, Pyykönen ML. Comparison of amoxicillin given two and three times a day in acute respiratory tract infections in children. Scand J Prim Health Care. 1986 Nov;4(4):201-4.

5. Vilas-Boas AL, Fontoura MS, Xavier-Souza G, Araújo-Neto CA, Andrade SC, BrimRV, Noblat L, Barral A, Cardoso MR, Nascimento-Carvalho CM; PNEUMOPAC-Efficacy Study Group. Comparison of oral amoxicillin given thrice or twice daily to children between 2 and 59 months old with non-severe pneumonia: a randomized controlled trial. J Antimicrob Chemother. 2014 Jul;69(7):1954-9.

6. Fonseca W, Hoppu K, Rey LC, Amaral J, Qazi S. Comparing pharmacokinetics of amoxicillin given twice or three times per day to children older than 3 months with pneumonia. Antimicrob Agents Chemother. 2003 Mar;47(3):997-1001.

7. Daschner FD, Behre U, Dalhoff A. Prospective clinical trial on the efficacy of amoxycillin administered twice or four times daily in children with respiratory tract infections. J Int Med Res. 1981;9(4):274-6.

8. WHO - Guidelines for the management of common childhood illnesses. http://www.who.int/maternal_child_adolescent/docum...

9. Baguley D, Lim E, Bevan A, Pallet A and Faust SN. Prescribing for children – taste and palatability affect adherence to antibiotics: a review Archives of Disease in Childhood 2012;97:293-297

10. Falagas ME, Karagiannis AKA, Nakouti T, Tansarli GS. Compliance with Once-Daily versus Twice or Thrice-Daily Administration of Antibiotic Regimens: A Meta-Analysis of Randomized Controlled Trials. PLoS ONE. 2015;10(1):e0116207. doi:10.1371/journal.pone.0116207.

11. Malhotra-Kumar S, Lammens C, Coenen S, Van Herck K, Goossens H. Effect of azithromycin and clarithromycin therapy on pharyngeal carriage of macrolide-resistant streptococci in healthy volunteers: a randomised, double-blind, placebo-controlled study. Lancet. 2007 Feb 10;369(9560):482-90.

12. Dancer SJ. Attention prescribers: be careful with antibiotics. Lancet. 2007 Feb 10;369(9560):442-3.

13. Bielicki JA, Barker CI, Saxena S, Wong IC, Long PF, Sharland M. Not too little, not too much: problems of selecting oral antibiotic dose for children. BMJ. 2015 Nov 3;351:h5447.

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

Click here for tips for antibiotic prescribing in children and the rationale for the changes in the 2018 guidelines.

Click here to listen to a podcast on respiratory tract infections in children.

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 months 125mg tds (off-label); 1-4 years: 250mg rds or 500mg bd (off-label); 5-11 years: 500mg tds or 750mg bd (off-label); ≥12 years: 600mg tds or 1 gram bd (off-label))

If no response to amoxicillin or consider if high risk of complications:

Co-amoxiclav tds for 5 days. Dose: 1-11 months: 0.25 m:/kg of 125/31 co-amoxiclav liquid tds. 1-5 years: co-amoxiclav 125/31 liquid 5 mL tds. 6-11 years: co-amoxiclav 250/62 liquid 5 mL tds. 12-17 years: co-amoxiclav tablets (500/125 mg) 1 tds or co-amoxiclav 250/62 liquid 10 mL tds.

Treatment for atypical infections should only be considered in severe infection if no response to first line empirical therapy/if allergic to penicillin:

Erythromycin for 5 days. Dose: 1-23 months: 250mg bd. 2-7 years: 500mg bd. 8-17 years: 1g bd.

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..

Provide safety netting information (verbal and written) (under 1's) (over 1's).

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.

References

1. https://www.brit-thoracic.org.uk/document-library/...

2. Vilas-Boas AL, Fontoura MS, Xavier-Souza G, Araújo-Neto CA, Andrade SC, BrimRV, Noblat L, Barral A, Cardoso MR, Nascimento-Carvalho CM; PNEUMOPAC-Efficacy Study Group. Comparison of oral amoxicillin given thrice or twice daily to children between 2 and 59 months old with non-severe pneumonia: a randomized controlled trial. J Antimicrob Chemother. 2014 Jul;69(7):1954-9.

3. Fonseca W, Hoppu K, Rey LC, Amaral J, Qazi S. Comparing pharmacokinetics of amoxicillin given twice or three times per day to children older than 3 months with pneumonia. Antimicrob Agents Chemother. 2003 Mar;47(3):997-1001.

4. Daschner FD, Behre U, Dalhoff A. Prospective clinical trial on the efficacy of amoxycillin administered twice or four times daily in children with respiratory tract infections. J Int Med Res. 1981;9(4):274-6.

5. WHO - Guidelines for the management of common childhood illnesses. http://www.who.int/maternal_child_adolescent/docum...

6. Baguley D, Lim E, Bevan A, Pallet A and Faust SN. Prescribing for children – taste and palatability affect adherence to antibiotics: a review Archives of Disease in Childhood 2012;97:293-297

7. Falagas ME, Karagiannis AKA, Nakouti T, Tansarli GS. Compliance with Once-Daily versus Twice or Thrice-Daily Administration of Antibiotic Regimens: A Meta-Analysis of Randomized Controlled Trials. PLoS ONE. 2015;10(1):e0116207. doi:10.1371/journal.pone.0116207.

8. Malhotra-Kumar S, Lammens C, Coenen S, Van Herck K, Goossens H. Effect of azithromycin and clarithromycin therapy on pharyngeal carriage of macrolide-resistant streptococci in healthy volunteers: a randomised, double-blind, placebo-controlled study. Lancet. 2007 Feb 10;369(9560):482-90.

9. Dancer SJ. Attention prescribers: be careful with antibiotics. Lancet. 2007 Feb 10;369(9560):442-3.

10. Bielicki JA, Barker CI, Saxena S, Wong IC, Long PF, Sharland M. Not too little, not too much: problems of selecting oral antibiotic dose for children. BMJ. 2015 Nov 3;351:h5447.

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

Click here for tips for antibiotic prescribing in children and the rationale for the changes in the 2018 guidelines.

Click here to listen to a podcast on respiratory tract infections in children.

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

For children 12 years or older consider prescribing high-dose nasal corticosteroids (equivalent to mometasone 400 micrograms a day) for 14 days instead of:

First line: Amoxicillin if no previous treatment in preceding 4 weeks. Dose: bd for 5 days. Dose per actual body weight (40mg/kg bd (max 1g per dose)) or using age bands (3-11 months: 125mg tds or 250mg bd (off-label); 1 year - 4 years: 250mg tds or 500mg bd (off-label); 5-11 years:500mg tds or 750mg bd (off-label) >12 years: 500mg tds or 1 gram bd (off-label)).

Or

Phenoxymethylpenicillin for 5 days. Dose: 1 to 11 months: 62.5mg qds or 125mg bd (off-label). 1 to 5 years. 125mg qds or 250mg bd (off-label). 6 to 11 years: 250mg qds or 500mg bd (off-label). 12 to 17 years: 500mg qds or 1g bd (off-label).


If treatment with amoxicillin in preceding 4 weeks: Co-amoxiclav tds for 5 days. For children 1-11 months: 0.25ml/kg of co-amoxiclav 125/31 liquid tds.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: Clarithromycin for 5 days. Dose: Under 8kg: 7.5mg/kg bd. 8 to 11kg: 62.5mg bd. 12 to 19kg: 125mg bd. 20 to 29kg: 187.5mg bd. 20 to 40kg: 250mg bd. 12 to 17 years: 500mg bd.

Or

Doxycycline (5-day course in total) 12 to 17 years: 200mg on first day, then 100mg once a day for 4 days.

Provide safety netting information (verbal and written).

Note: aim to use an antibiotic that minimises doing frequency and is palatable (if suspension prescribed) to optimise adherence. QDS penicillin V and flucloxacillin suspensions are not well tolerated by children. It can sometimes be challenging for children to swallow large volumes of suspensions. Most school age children (from above 4 years of age) can be taught to swallow tablets. The following website provides great information for parents on teaching their child to swallow tablets - www.pillswallowing.com


References

1. Vilas-Boas AL, Fontoura MS, Xavier-Souza G, Araújo-Neto CA, Andrade SC, BrimRV, Noblat L, Barral A, Cardoso MR, Nascimento-Carvalho CM; PNEUMOPAC-Efficacy Study Group. Comparison of oral amoxicillin given thrice or twice daily to children between 2 and 59 months old with non-severe pneumonia: a randomized controlled trial. J Antimicrob Chemother. 2014 Jul;69(7):1954-9.

2. Fonseca W, Hoppu K, Rey LC, Amaral J, Qazi S. Comparing pharmacokinetics of amoxicillin given twice or three times per day to children older than 3 months with pneumonia. Antimicrob Agents Chemother. 2003 Mar;47(3):997-1001.

3. Daschner FD, Behre U, Dalhoff A. Prospective clinical trial on the efficacy of amoxycillin administered twice or four times daily in children with respiratory tract infections. J Int Med Res. 1981;9(4):274-6.

4. WHO - Guidelines for the management of common childhood illnesses. http://www.who.int/maternal_child_adolescent/docum...

5. Baguley D, Lim E, Bevan A, Pallet A and Faust SN. Prescribing for children – taste and palatability affect adherence to antibiotics: a review Archives of Disease in Childhood 2012;97:293-297

6. Falagas ME, Karagiannis AKA, Nakouti T, Tansarli GS. Compliance with Once-Daily versus Twice or Thrice-Daily Administration of Antibiotic Regimens: A Meta-Analysis of Randomized Controlled Trials. PLoS ONE. 2015;10(1):e0116207. doi:10.1371/journal.pone.0116207.

7. Malhotra-Kumar S, Lammens C, Coenen S, Van Herck K, Goossens H. Effect of azithromycin and clarithromycin therapy on pharyngeal carriage of macrolide-resistant streptococci in healthy volunteers: a randomised, double-blind, placebo-controlled study. Lancet. 2007 Feb 10;369(9560):482-90.

8. Dancer SJ. Attention prescribers: be careful with antibiotics. Lancet. 2007 Feb 10;369(9560):442-3.

9. Bielicki JA, Barker CI, Saxena S, Wong IC, Long PF, Sharland M. Not too little, not too much: problems of selecting oral antibiotic dose for children. BMJ. 2015 Nov 3;351:h5447.

10. NICE guideline – sinusitis (acute): antimicrobial prescribing (2017). www.nice.org.uk/guidance/ng79

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

Click here for tips for antibiotic prescribing in children and the rationale for the changes in the 2018 guidelines.

Click here to listen to a podcast on respiratory tract infections in children.

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 likely to have a bacterial aetiology and are less likely to develop complications.

NOTE: if a child's symptoms are worsening after 3 days, think about other differentials including a peritonsillar abscess (quinsy) or Lemierre syndrome (Fusobacterium).

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: 125mg tds or 250mg bd (off-label); 1 year - 4 years: 250mg tds or 500mg bd(off-label); 5-11 years: 500mg tds or 750mg bd (off-label); >12 years: 500mg tds or 1 gram bd (off-label)).

Or

Phenoxymethylpenicillin (Penicillin V) for 7 days. Dose: 1-11 months: 125mg bd. 1-5 years: 250mg bd. 6-11 years: 500mg bd. 12-17 years: 1g bd.

Although there has been great anxiety about prescribing amoxicillin in patients with tonsillitis due to the risk of adverse events associated with EBV, there is considerable data to suggest that the use of amoxicillin does not significantly increase the risk of rash in acute EBV – see https://adc.bmj.com/content/101/5/500 . In addition, data suggests that EBV accounts for as little as 1% of tonsillitis presenting to doctors - see https://www.ncbi.nlm.nih.gov/pubmed/17904463 and more importantly, EBV is extremely rare prior in children below 12 years of age. For this reason, the current recommendation is to use amoxicillin suspension in young children (palatability) and penicillin V tablets for children able to swallow tablets (due to higher rates of EBV in this age group).

For children able to swallow tablets; Phenoxymethylpenicillin (Penicillin V) for 7 days. 6-11 years: 500mg bd. 12 years or over: 1g bd.

If allergic to penicillin: Clarithromycin for 5 days. Dose: 1 month to 11 years: Under 8kg: 7.5,g/kg bd. 8 to 11kg: 62.5mg bd. 12 to 19kg: 125mg bd. 20 to 29kg: 187.5mg bd. 30 to 40kg: 250mg bd. 12 to 17 years: 250mg to 500mg bd.

Or

Erythromycin for 5 days. Dose: 1 month to 1 year: 250mg bd. 2-7 years: 500mg bd. 8-17 years: 500mg to 1g bd.

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. It can sometimes be challenging for children to swallow large volumes of suspensions. Most school age children (from above 4 years of age) can be taught to swallow tablets. The following website provides great information for parents on teaching their child to swallow tablets - www.pillswallowing.com

References

1. NICE, Sore throat (acute): antimicrobial prescribing. [NG 84] January 2018 https://www.nice.org.uk/guidance/ng84 Date accessed June 2018

2. Spinks A, Glasziou PP, Del Mar CB. Antibiotics for sore throat. Cochrane Database Syst Rev. 2013; (11): CD000023. https://www.ncbi.nlm.nih.gov/pubmed/24190439

3. Little P, Williamson I, Warner G, Gould C, Gantley M, Kinmonth AL. Open randomised trial of prescribing strategies in managing sore throat. BMJ. 1997; 314(7082): 722-7. https://www.ncbi.nlm.nih.gov/pubmed/9116551

4. Petersen I, Johnson AM, Islam A, Duckworth G, Livermore DM, Hayward AC. Protective effect of antibiotics against serious complications of common respiratory tract infections: retrospective cohort study with the UK General Practice Research Database. BMJ. 2007; 335(7627): 982. http://www.bmj.com/content/335/7627/982

5. Little P, Stuart B, Hobbs FD, Butler CC, Hay AD, Campbell J, et al. Predictors of suppurative complications for acute sore throat in primary care: prospective clinical cohort study. BMJ. 2013; 347: f6867. http://www.bmj.com/content/347/bmj.f6867

6. Falagas ME, Vouloumanou EK, Matthaiou DK, Kapaskelis AM, Karageorgopoulos DE. Effectiveness and safety of short-course vs long-course antibiotic therapy for group a beta hemolytic streptococcal tonsillopharyngitis: a meta-analysis of randomized trials. Mayo Clin Proc. 2008; 83(8): 880-9. https://www.ncbi.nlm.nih.gov/pubmed/18674472

7. Lan AJ, Colford JM, Colford JM, Jr. The impact of dosing frequency on the efficacy of 10-day penicillin or amoxicillin therapy for streptococcal tonsillopharyngitis: A meta-analy http://adc.bmj.com/content/101/5/500sis. Pediatrics. 2000; 105(2): E19. https://www.ncbi.nlm.nih.gov/pubmed/10654979

8. Chovel-Senna A et al. Incidence of Rash After Amoxicillin Treatment in Children With Infectious Mononucleosis. Pediatrics. 2013 May;131(5):e1424-7

9. Chew C, Goenka A. QUESTION 2: Does amoxicillin exposure increase the risk of rash in children with acute Epstein-Barr virus infection? Arch Dis Child. 2016; 101(5): 500-2 . http://adc.bmj.com/content/101/5/500

10. Worrall GJ. Acute sore throat. Can Fam Physician. 2007 Nov; 53(11): 1961–1962.

11. Vilas-Boas AL, Fontoura MS, Xavier-Souza G, Araújo-Neto CA, Andrade SC, BrimRV, Noblat L, Barral A, Cardoso MR, Nascimento-Carvalho CM; PNEUMOPAC-Efficacy Study Group. Comparison of oral amoxicillin given thrice or twice daily to children between 2 and 59 months old with non-severe pneumonia: a randomized controlled trial. J Antimicrob Chemother. 2014 Jul;69(7):1954-9.

12. Fonseca W, Hoppu K, Rey LC, Amaral J, Qazi S. Comparing pharmacokinetics of amoxicillin given twice or three times per day to children older than 3 months with pneumonia. Antimicrob Agents Chemother. 2003 Mar;47(3):997-1001.

13. Daschner FD, Behre U, Dalhoff A. Prospective clinical trial on the efficacy of amoxycillin administered twice or four times daily in children with respiratory tract infections. J Int Med Res. 1981;9(4):274-6.

14. WHO - Guidelines for the management of common childhood illnesses. http://www.who.int/maternal_child_adolescent/docum...

15. Baguley D, Lim E, Bevan A, Pallet A and Faust SN. Prescribing for children – taste and palatability affect adherence to antibiotics: a review Archives of Disease in Childhood 2012;97:293-297

16. Falagas ME, Karagiannis AKA, Nakouti T, Tansarli GS. Compliance with Once-Daily versus Twice or Thrice-Daily Administration of Antibiotic Regimens: A Meta-Analysis of Randomized Controlled Trials. PLoS ONE. 2015;10(1):e0116207. doi:10.1371/journal.pone.0116207.

17. Malhotra-Kumar S, Lammens C, Coenen S, Van Herck K, Goossens H. Effect of azithromycin and clarithromycin therapy on pharyngeal carriage of macrolide-resistant streptococci in healthy volunteers: a randomised, double-blind, placebo-controlled study. Lancet. 2007 Feb 10;369(9560):482-90.

18. Dancer SJ. Attention prescribers: be careful with antibiotics. Lancet. 2007 Feb 10;369(9560):442-3.

19. Bielicki JA, Barker CI, Saxena S, Wong IC, Long PF, Sharland M. Not too little, not too much: problems of selecting oral antibiotic dose for children. BMJ. 2015 Nov 3;351:h5447.

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

Click here for tips for antibiotic prescribing in children and the rationale for the changes in the 2018 guidelines.

Click here to listen to a podcast on respiratory tract infections in 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 (if low rise of resistance). Dose: 3-5 months: 4 mg/kg bd (maxiumum 200mg per dose) or 25 mg bd. 6 months to 5 years: 4mg/kg bd (maciumum 200mg per dose) or 50mg bd. 6-11 years: 4mg/kg bd (maximum 200mg per dose) or 100mg bd. 12-15 years: 200mg bd.

Or

Nitrofurantoin: If can swallow tablets, previous treatment with trimethoprim in preceding 3 months and eGFR over 45ml/min/1.73m2. Dose: 3 months to 11 years: 750 micrograms/kg qds (use immediate release tablets). 12-17 years: 100mg m/r bd.

Or

Cefalexin - all doses off-label. 12.5mg/kg (max 1g per dose) tds or 3-11 months: 125mg tds. 1 to 4 years: 250mg tds. 5 to 11 years: 500mg tds. 12 years and over: 1g tds.

If confirmed severe penicillin allergy, sensitivities are not known and unable to swallow nitrofurantoin tablets:

Ciprofloxacin 10mg/kg bd (double dose in severe infection) max 750mg.

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

Empiric treatment: Do not use if unable to tolerate oral antibiotics or systemically unwell (suggestive of bacteraemia)

Duration of antibiotic course 7 days:

Cefalexin - all doses of label. 12.5mg/kg (max 1g per dose) tds. 3-11 months 125mg tds. 1 year to 4 years 250mg tds. 5 to 11 years 500mg tds. 12 years and over 1g tds.

If severe penicillin allergy: Ciprofloxacin 10mg/kg bd (double dose in severe infection) 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)

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. It can sometimes be challenging for children to swallow large volumes of suspensions. Most school age children (from above 4 years of age) can be taught to swallow tablets. The following website provides great information for parents on teaching their child to swallow tablets - www.pillswallowing.com

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



References

1. NICE. Urinary Tract Infection in Children 2007. (Clinical Guideline 54). http://www.nice.org.uk/CG54 (Accessed Jan 2018)

2. PHE. Diagnosis of UTI – Quick Reference Guide for primary care. June 2017 https://www.gov.uk/government/publications/urinary... (Accessed Jan 2018)

3. Strohmeier Y, Hodson EM, Willis NS, Webster AC, Craig JC. Antibiotics for acute pyelonephritis in children. Cochrane Database Syst Rev. 2014; 7

4. Michael M, Hodson EM, Craig JC, Martin S, Moyer VA. Short versus standard duration oral antibiotic therapy for acute urinary tract infection in children. Cochrane Database Syst Rev. 2003;(1):CD003966.

5. MHRA 2014. https://www.gov.uk/drug-safety-update/nitrofuranto...

6. Baguley D, Lim E, Bevan A, Pallet A and Faust SN. Prescribing for children – taste and palatability affect adherence to antibiotics: a review Archives of Disease in Childhood 2012;97:293-297

7. Bielicki JA, Barker CI, Saxena S, Wong IC, Long PF, Sharland M. Not too little, not too much: problems of selecting oral antibiotic dose for children. BMJ. 2015 Nov 3;351:h5447.

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

Click here for tips for antibiotic prescribing in children and the rationale for the changes in the 2018 guidelines.

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