Empirical antibiotic guidelines for children

Bites (animal and human)

When to treat

Assess the severity of the bite:

  • Site and depth of wound
  • Whether it is infected

Refer immediately to hospital if there are signs of a serious illness or a penetrating wound involving bones, joints, tendons or vascular structures.

Refer to A&E for further assessment and management if either:

  • Unable to irrigate and debride wound sufficiently
  • Unable to close the wound

Consider referral or seeking specialist advice if the person:

  • Is systemically unwell or has signs or symptoms remote from the bite
  • Has an infection after prophylactic antibiotics
  • Cannot take, or has an infection that is not responding to, oral antibiotics

Antibiotics are not generally needed if the wound is more than 2 days old and there is no sign of local or systemic infection.

Do not offer antibiotics if the bite has not broken the skin.1,2

Offer antibiotics if the bite is infected (e.g. increased pain, inflammation, fever, discharge or unpleasant smell).1,2 Take a swab for micro testing if there is discharge from the wound.

Establish what has caused the bite and select appropriate action below.

Reassess if:

  • Symptoms or signs of infection develop or worsen rapidly or significantly at any time
  • There is no improvement within 24 - 48 hours of starting treatment
  • The person becomes systemically unwell
  • There is severe pain that is out of proportion to the infection

 

PROPHYLAXIS:

Wild animals, exotic animals (including bird and non-traditional pets), bats, domestic animals you are unfamiliar with including farm animals:

Seek specialist advice from microbiologist or consultant in infectious diseases.1

Cat bite:

Offer antibiotics If the bite has broken skin and drawn blood1,2

Consider antibiotics if the bite has broken skin but not drawn blood if the wound could be deep.1,2

Do NOT offer antibiotics if the bite has broken skin but not drawn blood.1,2

Consider tetanus immunoglobulin if animal bite in children with incomplete tetanus immunisation status and administer vaccine if not received within past 10 years.

Consider rabies risk if animal from abroad.

Dog (or other traditional pet) bite:

Offer antibiotics if the bite has broken skin AND drawn blood IF it has caused considerable, deep tissue damage or is visibly contaminated (for example, with dirt or a tooth).1,2

Consider antibiotics if the bite has broken skin and drawn blood if the bite:1,2

  • Is to high risk area e.g. hands, feet, face, genitals, skin overlying cartilaginous structures or an area of poor circulation
  • Is in a person at high risk of serious wound infection due to co-morbidities such as diabetes, immunosuppression, asplenia or decompensated liver disease or presence of prosthetic valve/joint

Do NOT offer antibiotics if the bite has broken skin but not drawn blood.1,2

Consider tetanus immunoglobulin if animal bite in children with incomplete tetanus immunisation status and administer vaccine if not received within past 10 years.

Consider rabies risk if animal from abroad.

Human:

Thorough irrigation of the wound is important.

Offer antibiotics if the bite has broken skin and drawn blood.1,2

Consider antibiotics if the bite has broken the skin but not drawn blood and if the bite:

  • Is to high risk area e.g. hands, feet, face, genitals, skin overlying cartilaginous structures or an area of poor circulation
  • Is in a person at high risk of serious wound infection due to co-morbidities such as diabetes, immunosuppression, asplenia or decompensated liver disease

Do NOT offer antibiotics if the bite has broken skin but not drawn blood.1,2

Assess risk of tetanus, HIV, Hepatitis B & C and viral blood borne infection: Seek immediate advice from a consultant in microbiology or infectious diseases or PHE consultant in accordance with local processes / risk assessments. Consider if tetanus prophylaxis is required based on immunisation status and risk status of the wound.

 

TREATMENT:

If bite is infected, offer an antibiotic.

When to investigate1,2

If there is a discharge (purulent or non-purulent), take a swab for microbiological testing to guide treatment. State on the form that the swab is from an infected human bite or an infected animal bite.

 

Treatment choices

First line prophylaxis or treatment1,3

Co-amoxiclav (Total duration should be for 3 days (prophylaxis) or 5 days (treatment))

1-11 months: Co-amoxiclav 125/31/5ml liquid 0.25 mL/kg po TDS
1-5 years: Co-amoxiclav 125/31/5ml liquid 5 mL po TDS
6-11 years: Co-amoxiclav 250/62/5ml liquid 5 mL po TDS
12-17 years: Co-amoxiclav tablets (500/125 mg) 1 tablet po TDS or co-amoxiclav (250/62/5ml) liquid 10 mL po TDS

 

If allergic to penicillin1,3

Review child at 24 and 48 hours, as not all pathogens are covered.

Aged under 12 years old:

Co-trimoxazole po for 3 days for prophylaxis or 5 days for treatment

Child 6 weeks-5 months: 120mg po BD (off-label)

Child 6 months-5 years: 240mg po BD (off-label)

Child 6-11 years: 480mg po BD (off-label)

 

Aged 12 years and over:

Doxycycline Day 1: 200mg po STAT then Day 2 onwards 100mg or 200mg po OD.3 Total duration should be for 3 days for prophylaxis or 5-7 days for treatment. PLUS Metronidazole 400mg po TDS for 3 days for prophylaxis or 5-7 days for treatment.

 

General advice

Advise patient to seek medical help if an infection:

  • Develops or worsens rapidly or significantly at any time
  • Does not start to improve within 24 to 48 hours of starting treatment

References

  1. NICE. Human and animal bites: antimicrobial prescribing [NG184]. 11/20. Accessed at LINK 11/21
  2. NICE & PHE. Summary of antimicrobial prescribing guidance – managing common infections LINK accessed 11/21
  3. BNFc accessed at LINK 11/21

 

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

Click here for tips for antibiotic prescribing in children and the evidence base supporting them

Last updated

March 2022

Candidiasis (oral)

When to treat

Oral candidiasis is rare in immunocompetent people. Consider undiagnosed risk factors including HIV infection.1

Stop unnecessary antibiotics and advise parent/carer to sterilise dummy.3

 

Treatment choices:

Localised or mild infection - first line

Miconazole oral gel 20mg/g1

Continue for 7 days after lesions have healed or symptoms have cleared.2

For neonate and child under 2 years old, smear around the inside of the mouth after feeds.2

Child over 2 years: dental prostheses and orthodontic appliances should be removed at night and brushed with gel.2

 

Neonate: 1 mL by mouth BD to QDS after feeds2

1-23 months: 1.25 mL by mouth QDS after feeds2

2-17 years: 2.5 mL by mouth QDSafter meals, apply near oral lesions before swallowing

 

Localised or mild infection - second line (if miconazole not tolerated)

Nystatin oral suspension 100,000 units/ml1

Continue treatment for a further 2 days after lesions have healed2

Apply 1 mL by mouth QDS after feeds or meals2

 

Extensive or severe infection1

Fluconazole1 for 7-14 days (may be extended in severely immunocompromised patients)*

Child 1 month-11 years:2

 

Day 1: 3-6mg/kg (max dose 100mg) then from day 2 onwards: 3mg/kg daily (max dose 100 mg)

Child 12-17 years:2 50mg po OD (can be increased to 100mg po OD for unusually difficult infections2 or immunocompromised1)

* - Check drug interactions and contraindications when prescribing oral terbinafine using BNFc or Summary of Product Characteristics.

 

References

  1. NICE & PHE. Summary of antimicrobial prescribing guidance – managing common infections LINK accessed 12/21
  2. BNFc LINK accessed 12/21
  3. Antimicrobial paediatric prescribing summary for hospitals; UK PAS group LINK last updated 9/21, accessed 12/21

 

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

Click here for tips for antibiotic prescribing in children and the evidence base supporting them

Last updated

March 2022

Cellulitis

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). For facial cellulitis, see below.

If patient afebrile and tolerating oral antibiotics, can be managed in primary care. Caution with immunocompromised patients. NOTE: oral flucloxacillin (suspension) is extremely unpalatable and is poorly tolerated by the majority of children.

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 toxin testing.

First line

Cefalexin2 for 5-7 days

12.5mg/kg po BD (max 1g per dose) or

1-11 months: 125mg po BD

1-4 years: 125mg po TDS

5-11 years: 250mg po TDS

12 years and over: 500mg po BD-TDS

OR

Flucloxacillin for 5-7 days1,3

1-23 months: 62.5-125mg po QDS

2-9 years: 125-250mg po QDS

10-17 years: 250-500mg po QDS

If allergic to penicillin

Clarithromycin for days3

Under 8 kg: 7.5mg/kg po BD

8 to 11 kg: 62.5mg po BD

12 to 19 kg: 125mg po BD

20 to 29 kg: 187.5mg po BD

30 to 40 kg: 250mg po BD
12 to 17 years: 500mg po BD

OR

Erythromycin (if pregnant)3

8-17 years: 1g po BD2

 

FACIAL CELLULITIS:

If facial cellulitis

If severe facial cellulitis, refer to secondary care.

Co-amoxiclav1,2,3 for days3

1-11 months: co-amoxiclav 125/31/5ml liquid 0.25 mL/kg po TDS

1-5 years: co-amoxiclav 125/31/5ml liquid 5 mL po TDS (dose doubled in severe infection)

6-11 years: co-amoxiclav 250/62/5ml liquid 5 mL po TDS (dose doubled in severe infection)

12-17 years co-amoxiclav tablets (500/125 mg) 1 tablet po TDS or co-amoxiclav 250/62/5ml liquid 10 mL po TDS

 

If facial cellulitis and allergic to penicillin

Clarithromycin for days3

Under 8 kg: 7.5mg/kg po BD

8 to 11 kg: 62.5mg po BD

12 to 19 kg: 125mg po BD

20 to 29 kg: 187.5mg po BD

30 to 40 kg: 250mg po BD
12 to 17 years: 500mg po BD

PLUS (if anaerobes suspected)

Metronidazole for 7 days3

1 month: 7.5mg/kg po BD

2 months-11 years: 7.5mg/kg (max 400mg per dose) po TDS

12-17 years: 400mg po TDS

 

Cautions

Aim to use an antibiotic that minimises dosing frequency and is palatable (if suspension prescribed) to optimise adherence. Oral flucloxacillin (suspension) is extremely unpalatable and is poorly tolerated by the majority of children.

References

  1. NICE & PHE. Summary of antimicrobial prescribing guidance – managing common infections LINK accessed 11/21
  2. BNFc accessed at LINK 11/21
  3. NICE (2019). Cellulitis and erysipelas: antimicrobial prescribing.[NG141] 09/19. Accessed at LINK 11/21.
  4. NICE (2020). Impetigo: antimicrobial prescribing.[NG153] 02/20. Accessed at LINK 11/21

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

Click here for tips for antibiotic prescribing in children and the evidence base supporting them

 

Last updated

March 2022

Conjunctivitis

When to treat

Usually no treatment required; viral cause most likely (adenovirus, enterovirus, occasionally herpes simplex). Bacterial conjunctivitis: usually unilateral and also self-limiting. It is characterised by red eye with mucopurulent, not watery discharge. 65% and 74% resolve on placebo by days 5 and 7 respectively.

Treat only if severe as most cases are viral or self-limiting.

Consider ophthalmia neonatorum in a neonate; this does not refer to a simple “sticky eye” in a neonate and requires urgent review in hospital.

Safety netting

Provide written and verbal advice

 

Treatment choices for bacterial conjunctivitis

First line

Bathe / clean eyelids with cotton wool dipped in sterile saline or boiled (cooled) water (to remove crusting) TDS or QDS. Wipe away from the bridge of the nose to the side.

Advise patient / carer that good hand hygiene is required.

 

Second line3

Consider Chloramphenicol 0.5% eye drops (apply 1 drop every 2 hours then reduce frequency as infection is controlled, frequency dependent on the severity of the infection. For less severe infection 3-4 times daily is generally sufficient)

PLUS Chloramphenicol eye ointment 1% (Apply at night)

Continue until 2 days after symptoms resolved.

There was a MHRA drug safety alert regarding Chloramphenicol eye drops containing borax or boric acid buffers: use in children younger than 2 years in July 2021. This contains counselling points for parents / carers of children under 2 years old. Please use this information to support discussions if prescribing chloramphenicol eye drops for children under 2 years old.

 

General advice

Advise patient about self-management:

  • Exercise hand hygiene and avoid sharing towels or pillows
  • Avoid contact lenses until symptoms have cleared
  • Public Health England (PHE) advises that it is not necessary to stay away from school unless the patient is feeling particularly unwell: https://www.nhs.uk/conditions/conjunctivitis/#work-and-school

 

Arrange follow up to confirm diagnosis and ensure that symptoms have resolved.

Consider referral to ophthalmology if symptoms persist for more than 7 to 10 days after initiating treatment.

 

References

  1. NICE CKS. Conjunctivitis – infective. Last revised 04/21. Accessed at LINK 4/21
  2. Management of acute infective conjunctivitis. Drug and Therapeutics Bulletin 2011; 49(7): 78-80 LINK
  3. NICE and PHE. Summary of antimicrobial prescribing guidance – managing common infections LINK. Updated 03/21

 

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

Click here for tips for antibiotic prescribing in children and the evidence base supporting them

 

Last updated

March 2022

Fungal skin and nail infections

DERMATOPHYTE INFECTION - SKIN / SCALP

When to treat

The diagnosis of suspected fungal infection of the body and groin should be made on the basis of clinical features.1

 

When to investigate

Send skin scrapings if intractable infection or infection of the scalp.2,3

 

General advice

Wash the affected skin daily and dry thoroughly afterwards, wash clothes and bed linen frequently, don’t share towels and wash them frequently, wear loose-fitting clothes made of cotton.1

 

Treatment choices

Licensing of topical and oral azoles varies. Check with local formularies before prescribing.

 

Topical products

Body

Terbinafine2 1% cream apply thinly OD-BD for 1-2 weeks, review treatment after 2 weeks4

Or

Imidiazole2 cream for 4-6 weeks2. See local formulary for product choice.

 

Candida infection (suspected and confirmed)

Imidazole cream2 continued for 1-2 weeks after healing1

  

Foot (athelete’s foot)

Topical undecenoates e.g. Mycota® which should be applied BD. Continue use for 7 days after lesions have healed.4

 

Scalp

Oral terbinafine (dosing as below). If not responding after 6 weeks, review. Refer if no regeneration of hair to a specialist.

 

Body

Oral terbinafine (dosing as below) for 4 weeks4

  

Groin

Oral terbinafine (dosing as below) for 2-4 weeks4

  

Foot

Oral terbinafine (dosing as below) for 2-6 weeks4

 

DERMATOPHYTE INFECTIONS (NAILS)

When to treat

Take nail clippings. Start therapy only if infection is confirmed.1

Treatment choices

Oral terbinafine.

6 week treatment course for fingernails, 12 weeks for toenails. If not responding after 6-12 weeks, review and seek dermatology specialist advice.

 

Oral terbinafine dosing

If infection is intractable and infection has been CONFIRMED:

Terbinafine4 dosing for children 1-17 years:

Weight 10-19 kg: 62.5mg po OD

Weight 20-39 kg: 125mg po OD

Weight 40 kg and above: 250mg po OD

 

If prescribing oral terbinafine: monitor LFTs before treatment and then periodically after 4-6 weeks of treatment. Discontinue if abnormalities in liver function tests.4

Check drug interactions and contraindications when prescribing oral terbinafine using BNFc or Summary of Product Characteristics.

 

References

1.      NICE CKS. Fungal skin infection – body and groin. Last revised 05/18. Available via LINK accessed 11/21

2.      NICE & PHE. Summary of antimicrobial prescribing guidance – managing common infections LINK accessed 11/21

3.      NICE CKS. Fungal skin infection – scalp. Last revised 04/18. Available via LINK accessed 11/21

4.      BNFc accessed LINK 11/21

5.      NICE CKS. Candida – skin. Last revised 05/17. Available via LINK accessed 11/21

6.      NICE CKS. Fungal skin infection – foot. Last revised 04/18. Available via LINK. accessed 11/21

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

Last updated

March 2022

Impetigo

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.

When to investigate

Most children with 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.

Treatment choices

Localised non-bullous impetigo

Use a topical antiseptic, such as Hydrogen peroxide 1% cream1, applied BD-TDS2 for 5-7 days1,2

OR

Use topical antibiotics (Fusidic acid 2% cream or Mupirocin 2% ointment)1 TDS for 5-7 days1,2

Widespread non-bullous or bullous impetigo with systemic symptoms

Treat with oral antibiotics (oral flucloxacillin (suspension) is extremely unpalatable and is poorly tolerated by the majority of children):

Cefalexin2 for 5-7 days

12.5mg/kg po BD (max 1g per dose) or

1-11 months: 125mg po BD

1-4 years: 125mg po TDS

5-11 years: 250mg po TDS

12 years and over: 500mg po BD-TDS

OR

Flucloxacillin for 5-7 days1,3

1-23 months: 62.5-125mg po QDS

2-9 years: 125-250mg po QDS

10-17 years: 250-500mg po QDS

If allergic to penicillin

Clarithromycin for days3

Under 8 kg: 7.5mg/kg po BD

8 to 11 kg: 62.5mg po BD

12 to 19 kg: 125mg po BD

20 to 29 kg: 187.5mg po BD

30 to 40 kg: 250mg po BD
12 to 17 years: 500mg po BD

OR

Erythromycin (if pregnant)3

8-17 years: 1g po BD2

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

Click here for tips for antibiotic prescribing in children and the evidence base supporting them

Last updated

March 2022

Insect bites

When to treat

Most insect bites or stings will not need antibiotics.1

Consider prescribing antihistamine in patients over 1 year old to help relieve itching.1,2

Do NOT offer antibiotics if there are no signs or symptoms of infections.1,2

 

If signs of symptoms of infection see Cellulitis section

 

References

1.      NICE. Insect bites and stings: antimicrobial prescribing. [NG182]. September 2020. Accessed at LINK 11/21

2.      NICE & PHE. Summary of antimicrobial prescribing guidance – managing common infections LINK accessed 11/21

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

Click here for tips for antibiotic prescribing in children and the evidence base supporting them

Last updated

March 2022

Lymphadenitis

When to treat

If cervical lymphadenopathy is bilateral, non-erythematous, non- tender, with node size less than 3cm, and child systemically well, consider a no treatment, watchful waiting approach.

Low threshold for treatment if child immunocompromised. 

If child is systemically unwell with cervical lymphadenitis symptoms, this is suggestive of acute bacterial cause - treat with antibiotics.3

 

RED FLAGS requiring an URGENT review and ENT input:       

    • Stertor or stridor suggesting airway obstruction
    • Difficulty swallowing/drooling
    • Muffled speech
    • Torticollis (can occur in minor infections but potential sign of retropharyngeal infection)
    • Severe respiratory distress
    • Haemodynamic instability / sepsis (may require urgent source control)

 

Safety netting

Provide verbal and written advice

 

Treatment choices

If mild/moderate infection

Cefalexin3 for 7 days

 

1-11 months: 125mg po BD1

1-4 years: 125mg po TDS1

5-11 years: 250mg po TDS1

12 years and over: 500mg po BD-TDS1

 

If allergic to penicillin

Clarithromycin1,3 for 7 days

Weight-based for 1 month to 11 years:

Under 8 kg: 7.5mg/kg po BD

8-11 kg: 62.5mg po BD

12-19 kg: 125mg po BD

20-29 kg: 187.5mg po BD

30-40 kg: 250mg po BD

12 - 17 years: 500mg po BD

 

Cautions

Aim to use an antibiotic that minimises dosing frequency and is palatable (if suspension prescribed) to optimise adherence. Oral flucloxacillin (suspension) is extremely unpalatable and is poorly tolerated by the majority of children.

References

1.      BNFc accessed at LINK 11/21

2.      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 LINK

3.      Antimicrobial paediatric prescribing summary for hospitals; UK PAS group LINK last updated 9/21, accessed 12/21 

 

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

Click here for tips for antibiotic prescribing in children and the evidence base supporting them

 

Last updated

March 2022

Otitis Externa

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

When to treat

If cellulitis and disease extending outside ear canal, start oral antibiotics based on sensitivities and arrange urgent ENT review.

 

Treatment choices

First line

Ear spray Acetic acid 2% (EarCalm spray®) ONE spray TDS for 7 days1 (unlicensed use)

Analgesia for pain relief and apply localised heat (such as a warm flannel)1,3

 

Second line

Aminoglycoside + steroid (contraindicated in perforated tympanic membrane)3:

Neomycin + steroid ear drops / spray:

Drops: Betnesol-N® , Otosporin® THREE drops TDS for 7 - 14 days (or equivalent generic product). See BNFc for duration for each product.

Spray: Otomize® ear spray ONE spray TDS for 7 - 14 days

Gentamicin + steroid ear drops1:

Gentisone HC® TWO to FOUR drops instilled in the affected ear FOUR or FIVE times a day, (including a dose at bedtime) for 7 - 14 days (or equivalent generic product)

 

If cellulitis and disease extending outside ear canal, start oral antibiotics based on sensitivities

Empirical treatment:

Cefalexin (off-label) for 5 - 7 days

12.5mg/kg po BD (max 1g per dose) or

1-11 months: 125mg po BD2

1-4 years: 125mg po TDS2

5-11 years: 250mg po TDS2

12 years and over: 500mg po BD-TDS2

 OR

Flucloxacillin1,2 for 5 - 7 days

1-23 months: 62.5mg - 125mg po QDS2

2-9 years: 125mg - 250mg po QDS2

10-17 years: 500mg po QDS2

 

If cellulitis as above and allergic to penicillin

Erythromycin for 5 - 7 days2

1-23 months: 250mg po BD

2-7 years: 500mg po BD

8-17 years: 1g po BD

OR

Clarithromycin for 5 - 7 days2

Weight-based for 1 month to 11 years:

Under 8 kg: 7.5mg/kg po BD

8-11 kg: 62.5mg po BD

12-19 kg: 125mg po BD

20-29 kg: 187.5mg po BD

30-40 kg: 250mg po BD

12-17 years: 500mg po BD

 

Safety netting

Provide verbal and written advice

 

Cautions

Aim to use an antibiotic that minimises dosing frequency and is palatable (if suspension prescribed) to optimise adherence. Oral flucloxacillin (suspension) is extremely unpalatable and is poorly tolerated by the majority of children.

 

References

 

1.      NICE & PHE. Summary of antimicrobial prescribing guidance – managing common infections LINK accessed 11/21

2.      BNF-C accessed at LINK in November 2021

3.      NICE CKS: Otitis externa. Last revised 02/18. Accessed LINK 11/21

4.      Malhotra-Kumar S et al. 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.

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

Click here for tips for antibiotic prescribing in children and the evidence base supporting them

 

Last updated

March 2022

Otitis Media

When to treat

Acute otitis media (AOM) resolves in 60% by 24 hours with or without antibiotics, acute complications are rare. Antibiotics only marginally reduce pain at 2 days (NNT 24) and do not prevent deafness. Need to treat 4800 with antibiotics to avoid 1 case of mastoiditis. Antibiotics make little difference to rates of recurrence of infection and perforated ear drum. Adverse events (vomiting, diarrhoea or rash) from antibiotics are significantly increased in children with AOM vs placebo (NNH 13).1

Optimise management of pain - regular paracetamol or ibuprofen for pain (right dose for age or weight at the right time and maximum doses for severe pain).1

Otitis media can be associated with CNS complications, even in young children:

RED FLAGS raising possibility of CNS complications:

  • Severe headache persisting despite regular analgesia (ibuprofen and paracetamol) or worse on lying down / in morning
  • Severe retroorbital pain
  • Persistent vomiting
  • New onset squint or diplopia - covering up one eye
  • Deteriorating vision - complaining of blurred vision
  • New limb weakness – may exhibit change of hand preference
  • Unsteady gait or coordination issues
  • Increasing drowsiness
  • Meningism / irritability

Children over 2 years: 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 not improving after 3 days1
  • Purulent discharge from ear canal (ottorhoea) not due to otitis externa1
  • Systemically unwell1
  • Has high risk of complications1

Children aged 6 months-2 years, start antibiotics if any of the following:

  • Bilateral AOM, or
  • Purulent discharge from ear canal (ottorhoea) not due to otitis externa
  • Symptoms not improving after 3 days

Children under 6 months – start antibiotics if presumed AOM

 

When to consider back up prescription

Consider a back-up / watchful waiting or no prescription in children who do not fit the criteria above, including those with no otorrhoea. It is considered that most children will fall into this category, i.e. not require an immediate prescription.

 

Safety netting

Provide verbal and written advice

 

Treatment choices

First line if antibiotics indicated

Amoxicillin for 5 days

40mg/kg po BD (max 1g per dose) (off-label)

Or by age:

1-11 months: 125mg po TDS1 or 250mg po BD6 (off-label)

1-4 years: 250mg po TDS1 or 500mg po BD6 (off-label)

5-11 years: 500mg po TDS1 or 750mg po BD6 (off-label)

12 years and over: 500mg po TDS1 or 1g po BD6 (off-label)

 

If allergic to penicillin

Clarithromycin for 5 days1

Weight-based for 1 month to 11 years:

Under 8 kg: 7.5mg/kg po BD

8-11 kg: 62.5mg po BD

12-19 kg: 125mg po BD

20-29 kg: 187.5mg po BD

30-40 kg: 250mg po BD

12-17 years: 500mg po BD

Or

Erythromycin for 5 days1

1-23 months: 250mg po BD

2-7 years: 500mg po BD

8-17 years: 1g po BD

 

If failed on first line (worsening symptoms on first choice taken for at least 2 to 3 days)

Co-amoxiclav for 5 days1

 

1-11 months: co-amoxiclav 125/31/5ml liquid 0.25mL/kg po TDS
1-5 years: co-amoxiclav 125/31/5ml liquid 5 mL po TDS
6-11 years: co-amoxiclav 250/62/5ml liquid 5 mL po TDS

12-17 years: co-amoxiclav tablets (500/125 mg) 1 po TDS or co-amoxiclav (250/62/5ml) liquid 10 mL po TDS

If penicillin allergy: Send swab and treat in accordance with results. If further advice required consult local microbiologist.

 

Cautions

Aim to use an antibiotic that minimises dosing frequency and is palatable (if suspension prescribed) to optimise adherence.

 

References

1.      NICE NG91 Otitis media (acute): antimicrobial prescribing, 03/18 LINK accessed 09/19

2.      NICE & PHE. Summary of antimicrobial prescribing guidance – managing common infections LINK accessed 11/21

3.      Hoberman A et al. Treatment of acute otitis media in children under 2 years of age. N Engl J Med. 2011; 364(2): 105-15. LINK

4.      Thompson PL et al. 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. LINK

5.      Valtonen M et al. 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.

6.      WHO - Recommendations for management of common childhood 2012 conditions. LINK accessed 11/21

 

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

Click here for tips for antibiotic prescribing in children and the evidence base supporting them

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

 

Last updated

March 2022

Pneumonia

When to treat1

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.

Differentials for the child with cough or respiratory distress include:

  • Bronchiolitis
  • Viral induced wheeze
  • Acute exacerbation of asthma
  • Croup
  • Inhaled foreign body
  • Pertussis
  • Pneumothorax
  • Metabolic acidosis e.g. DKA
  • Heart failure

 If mild severity (child younger than 5 years with absence of persistent / recurrent fever over preceding 24-48 hours, no respiratory distress and no tachypnoea), antibiotics are not indicated. Provide verbal and written safety netting advice.

If moderate severity (persistent / recurrent fever over preceding 24-48 hours, respiratory distress and/or tachypnoea) and presumed diagnosis of CAP (see differentials above), treat with oral antibiotics and provide verbal and written safety netting advice.

In severe disease: Urgent review in hospital required. Features of severe disease include:

  • Significant tachypnoea*
  • Significant tachycardia*
  • Severe respiratory distress (significant recession (age younger than12 months), nasal flaring, grunting)
  • Apnoeas (ages younger than 12 months)
  • Hypoxia (sustained O2 sats 92% or less in room air)
  • Cyanosis
  • Signs of severe dehydration
  • Capillary Refill Time longer than 2 seconds

* - Parameters for significant tachycardia / tachypnoea:

·                Age younger than 6 months: Respiratory rate greater than 70, heart rate greater than 170

·                Age 6-11 months: Respiratory rate greater than 70, heart rate greater than 170

·                Age 12-35 months: Respiratory rate greater than 50, heart rate greater than 150

·                Age 3-4 years: Respiratory rate greater than 50, heart rate greater than 140

·                Age 5-13 years: Respiratory rate greater than 40, heart rate greater than 120

·                Age 14-17 years: Respiratory rate greater than 30, heart rate greater than 100

 Safety netting

Provide written and verbal advice:

Treatment choices

First line (if no previous treatment in preceding 4 weeks)

Amoxicillin2,3 for days4

40mg/kg po BD (max 1g per dose) (off-label)5

Or by age:

3-11 months: 125mg po TDS2 or 250mg po BD5 (off-label)

1-4 years: 250mg po TDS2 or 500mg po BD5 (off-label)

5-11 years: 500mg po TDS2 or 750mg po BD5 (off-label)

12 years and over: 500mg po TDS2 or 1g po BD5 (off-label)

If no response to amoxicillin OR if considered high risk of complications

Co-amoxiclav for 5 days2

1-11 months125/31/5ml co-amoxiclav liquid 0.5 mL/kg po TDS

1-5 years: co-amoxiclav 125/31/5ml liquid 10 mL po TDS

6-11 years: co-amoxiclav 250/62/5ml liquid 10 mL po TDS

12-17 years: co-amoxiclav tablets (500/125 mg) 1 tablet po TDS or co-amoxiclav 250/62/5ml liquid 10 mL po TDS

  

If allergic to penicillin OR if no response to first line empirical therapy

Clarithromycin1,3 for 5 days

Weight-based for 1 month to 11 years:

Under 8 kg: 7.5mg/kg po BD

8-11 kg: 62.5mg po BD

12-19 kg: 125mg po BD

20-29 kg: 187.5mg po BD

30-40 kg: 250mg po BD

12 - 17 years: 500mg po BD

OR

Erythromycin2 for 5 days

1-23 months: 250mg po BD6

2-7 years: 500mg po BD6

8-17 years: 1g po BD6

 

Cautions

Aim to use an antibiotic that minimises dosing frequency and is palatable (if suspension prescribed) to optimise adherence.

References

  1. British Society for Antimicrobial Chemotherapy. Paediatric pathways, pneumonia/empyema. Accessed at LINK 11/21
  2. NICE. Pneumonia (community-acquired): antimicrobial prescribing [NG138]. September 2019. Accessed at LINK  12/21
  3. NICE & PHE. Summary of antimicrobial prescribing guidance – managing common infections LINK accessed 12/21
  4. Bielicki J.A. et al. Effect of Amoxicillin Dose and Treatment Duration on the Need for Antibiotic Re-treatment in Children With Community-Acquired Pneumonia. The CAP-IT Randomized Clinical Trial. JAMA.2021;326(17):1713-1724.
  5. WHO - Recommendations for management of common childhood 2012 conditions. LINK accessed 12/21
  6. BNFc accessed at LINK 12/21
  7. Fonseca W et al. 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.

 

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

Click here for tips for antibiotic prescribing in children and the evidence base supporting them

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

 

Last updated

March 2022

Rhinosinusitis

When to treat

  • Generally antibiotics are not required. Majority of cases resolve in 14-21 days without them (regardless of cause; bacterial or viral)
  • Offer adequate analgesia
  • Consider treating with antibiotic if most of the following are present:1
    • Symptoms for more than 10 days
    • Marked deterioration after an initial milder phase
    • Fever
    • Unremitting purulent nasal discharge
    • Severe localised unilateral pain (particularly pain over teeth and jaw)

Sinusitis can be associated with CNS complications. This is rare in children under 8 years old. RED FLAGS raising possibility of CNS complications include:

  • Severe headache persisting despite regular analgesia (ibuprofen and paracetamol) or worse on lying down / in morning
  • Severe retroorbital pain
  • Persistent vomiting
  • New onset squint or diplopia - covering up one eye
  • Deteriorating vision - complaining of blurred vision
  • New limb weakness – may exhibit change of hand preference
  • Unsteady gait or coordination issues
  • Increasing drowsiness
  • Meningism / irritability

If a child has these symptoms, consider urgent referral to secondary care (paediatrics)

 

Treatment choices

For children 12 years or older consider prescribing high-dose nasal corticosteroids (equivalent to mometasone 200 micrograms twice a day) for 14 days instead of antibiotics1 (off-label use).

 

First line antibiotics

Amoxicillin for 5 days - if no previous antibiotic treatment in preceding 4 weeks

40mg/kg po BD6 (max 1g per dose) (off-label)

 
Or by age 
3-11 months: 125mg po TDS2 or 250mg po BD6 (off-label)
1-4 years: 250mg po TDS2 or 500mg po BD6 (off-label)
5-11 years: 500mg po TDS2 or 750mg po BD6 (off-label)
12 years and over: 500mg po TDS2 or 1 gram po BD6 (off-label)

OR

Phenoxymethylpenicillin (Penicillin V) for 5 days

1-11 months: 62.5mg po QDS1 or 125mg po BD (off-label)
1-5 years: 125mg po QDS1 or 250mg po BD (off-label)
6-11 years:  250mg po QDS1 or 500mg po BD (off-label)
12-17 years: 500mg po QDS1 or 1g po BD (off-label)

If treatment with amoxicillin in preceding 4 weeks or consider high risk of complications

Co-amoxiclav for 5 days1,2

1-11 months: co-amoxiclav 125/31/5ml liquid 0.25mL/kg po TDS
1-5 years: co-amoxiclav 125/31/5ml liquid 5 mL po TDS
6-11 years: co-amoxiclav 250/62/5ml liquid 5 mL po TDS
12-17 years: co-amoxiclav tablets (500/125 mg) 1 po TDS or co-amoxiclav (250/62/5ml) liquid 10 mL po TDS

 

If allergic to penicillin

Clarithromycin for 5 days1

Under 8 kg: 7.5mg/kg po BD

8-11 kg: 62.5mg po BD

12-19 kg: 125mg po BD

20-29 kg: 187.5mg po BD

30-40 kg: 250mg po BD
12-17 years: 500mg po BD

OR

Doxycyclinefor total of 5 days

12 to 17 years: 200mg po on first day, then 100mg OD 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. NICE guideline NG79 (2017) Sinusitis (acute): antimicrobial prescribing. Accessed at LINK 11/21
  2. BNFc accessed at LINK 11/21
  3. Vilas-Boas AL et al. 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.
  4. Fonseca W et al. 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.
  5. Daschner FD et al. 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.
  6. WHO - Recommendations for management of common childhood 2012 conditions. LINK accessed 11/21
  7. Malhotra-Kumar Set al. 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.

 

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

Click here for tips for antibiotic prescribing in children and the evidence base supporting them

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

 

Last updated

March 2022

Scarlet fever

When to treat1

  • If signs of sepsis, refer to Sepsis Pathway
  • If suspicion of invasive group A streptococcal infections refer urgently to hospital.
  • The rash begins with papular lesions on the body that then spread to the neck, arms. The rash is often accentuated in flexural creases but tends to spare the palms and soles of the feet.
  • The rash is not pruritic but has a characteristic sand-paper feel to it.
  • Associated symptoms include:
    • Sore throat/tonsillitis
    • Fever
    • Painful cervical lymphadenopathy
    • Strawberry tongue
  • The presence of coryzal symptoms, cough or diarrhoea, make a diagnosis of scarlet fever unlikely.
  • Optimise management of pain.

General advice1

  • Advise the family to keep child away from school/nursery for 1 day after starting antibiotic treatment, wash their hands frequently, avoid sharing eating utensils and towels, dispose of tissues promptly, and avoid contact with anyone at particular risk of infection (e.g. people with valvular disease or who are immunocompromised).  

Safety netting

Provide written and verbal advice

 

Treatment choices

Notify the local health protection team promptly within 3 days by completing a notification form if a diagnosis of scarlet fever is suspected.

For children unable to swallow tablets

Amoxicillin for 7 days1

40mg/kg po BD4 (max 1g per dose) (off-label)

Or by age:

3-11 months: 125mg po TDS2 or 250mg po BD4 (off-label)

1-4 years: 250mg po TDS2 or 500mg po BD4 (off-label)

5-11 years: 500mg po TDS2 or 750mg po BD4 (off-label)

12 years and over: 500mg po TDS2 or 1g po BD4 (off-label)

OR

Phenoxymethylpenicillin (Penicillin V) for 7 days1,3

1-11 months: 125mg po BD2

1-5 years: 250mg po BD2

6-11 years: 500mg po BD2

12-17 years: 1g po BD2

  

For children able to swallow tablets

Phenoxymethylpenicillin (Penicillin V) for 7 days1,3

6-11 years: 500mg po BD2
12-17 years: 1g po BD2

 

If allergic to penicillin

Clarithromycin2,3 for 5 days3

Under 8 kg: 7.5 mg/kg po BD2

8-11 kg: 62.5mg po BD2

12-19 kg: 125mg po BD2

20-29 kg: 187.5mg po BD2

30-40 kg: 250mg po BD2

12-17 years: 250-500mg po BD2

OR

Erythromycin (if pregnant)

8-17 years: 1g po BD2

 

Cautions

Aim to use an antibiotic that minimises dosing frequency and is palatable (if suspension prescribed) to optimise adherence.

Phenoxymethylpenicillin (penicillin V) and flucloxacillin suspensions given QDS are not well tolerated by children.

 

References

  1. NICE CKS. Scarlet fever. Last revised 03/20. Accessed LINK 11/21
  2. BNFc accessed at LINK 12/21
  3. NICE & PHE. Summary of antimicrobial prescribing guidance – managing common infections LINK accessed 12/21
  4. WHO - Recommendations for management of common childhood 2012 conditions. LINK accessed 11/21

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

Click here for tips for antibiotic prescribing in children and the evidence base supporting them

Last updated

March 2022

Scabies

When to treat1

Scabies is rare in children under 2 months of age. Seek specialist advice (e.g. from a paediatric dermatologist) if treatment is required for this age group.

The main symptom is generalised itch – especially at night. Itch may not be apparent in young babies or people with neurological conditions with decreased or loss of sensation. Characteristic silvery lines may be seen in the skin where mites have burrowed. Erythematous papular or vesicular lesions are often associated with the burrows. Typical sites include the interdigital folds, wrists, elbow, penis and scrotum in men and around the nipples in women.

Simultaneously (within 24 hours) treat the infected person and all members of the household, close contacts and sexual contacts even in the absence of symptoms. 

Also treat scabies that has become infected with an antibiotic.

 

Treatment choices

First line

Permethrin 5% cream.2 Apply as described below, in two applications, 7 days apart.2 Wash off after 8-12 hours.1,3

Apply the treatment from the chin and ears downwards paying special attention to the areas between the fingers and toes and under the nails.2

In patients under 2 years old and immunosuppressed patients, the insecticide should be applied to the whole body including the face and scalp.1.2

If treatment is washed off with soap within 8 hours of application (e.g. hand washing), it should be reapplied.3

Treatment should be applied to cool, dry skin – not after a hot bath, and allowed to dry before the person dresses in clean clothes.1

 

If not tolerated or allergy to permethrin or excipients or chrysanthemums

Malathion 0.5% aqueous liquid.2 Apply as described below, in two applications, 7 days apart.2 Wash off after 24 hours.1,3

Apply the treatment to the whole body including the face and scalp, paying special attention to the areas between the fingers and toes and under the nails.2

If treatment is washed off with soap within 24 hours of application (e.g. hand washing), it should be reapplied.3

Treatment should be applied to cool, dry skin – not after a hot bath, and allowed to dry before the person dresses in clean clothes.1

 

General advice

Seek specialist advice from a consultant dermatologist for the management of anyone presenting with crusted scabies; admission may be required.1

Ask about the person's living conditions, or whether close contacts/family members have also reported itching.1

Itch may persist for up to two weeks after successful treatment. If itching continues for longer than two to four weeks after the last treatment application advise the person to seek follow up.1

Consider symptomatic treatment for itching.

Machine wash (at 60°C or above) clothes, towels, and bed linen, on the day of application of the first treatment. Dry in a hot dryer, or dry cleaning or by sealing in a plastic bag for at least 72 hours.1

If recurrence occurs where all contacts were treated simultaneously and treatment was applied correctly, give a course of a different insecticide. 1

 

References 

1.      NICE CKS Scabies LINK revised 11/17 accessed 07/21

2.      NICE & PHE. Summary of antimicrobial prescribing guidance – managing common infections LINK accessed 11/21

3.      BNFc accessed at LINK in 11/21

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

Last updated

March 2022

Threadworm

When to treat1

Threadworms do not always cause symptoms but they can cause extreme itching around the perianal/perineal area particularly at night that can interrupt sleep. The eggs are deposited nocturnally by the adult worms. Treat if threadworms have been seen or their eggs have been detected. All members of the household should be treated at the same time even if asymptomatic (unless treatment is contraindicated).

When to investigate1

If the diagnosis is uncertain, the adhesive tape test for eggs may be useful – the tape should be examined under a microscope by GP or local laboratory. This may need to be examined on 3 consecutive mornings to confirm diagnosis. If there are frequent recurrences, consider seeking advice from a paediatrician or a consultant in infectious diseases.

General advice1

In conjunction with treatment, advise rigorous hygiene measures for 2 weeks (hand hygiene, cutting fingernails regularly, avoid biting nails and scratching around anus, wearing close fitting pants at night, morning shower including washing of the perianal area). Avoid sharing towels and flannels. This should be continued for 2 weeks if treated with mebendazole and 6 weeks if using hygiene measures alone.

PLUS wash sleepwear and bed linen daily for several days after treatment and thoroughly dust and vacuum (including mattresses) and clean bathroom.

No exclusion from nursery or school is required.1

Child younger than 6 months - add perianal wet wiping or washes three hourly.2

Treatment:

First line for children aged 6 months-17 years1,2,3

Mebendazole 100 mg orally for 1 dose. If reinfection occurs, second dose may be needed after 2 weeks.

Mebendazole is not licensed for use in children under 2 years.

Note: This can be purchased from a pharmacy if the patient is over 2 years of age, in line with NHS OTC consultation.

(Pripsen® (piperazine and senna) is no longer available in the UK).4

First line for children aged younger than 6 months:1

6 weeks strict hygiene (alone) to prevent faecal-oral re-infection2

Evidence

Mebendazole does not kill the eggs, eggs can live up to 2 weeks outside the body, therefore adequate personal and environmental hygiene is essential to prevent re-infestation from recently swallowed eggs, or eggs already in the environment.

Evidence for mebendazole is limited based on old, small studies comparing mebendazole with placebo or drugs not available in the UK but it is thought to have a high cure rate3. It has few contraindications and post-marketing surveillance has revealed no serious safety concerns.1

Hygiene measures, plus physical removal advice is based on expert opinion.1

References

1) NICE. Threadworm. Clinical Knowledge Summary. [Online] Last revised Feb 2018. LINK accessed 11/19

2) NICE and PHE. Summary of antimicrobial prescribing guidance – managing common infections LINK accessed 11/19

3) BNFC[Online] 2020. LINK

4) TOXBASE(R) Threadworm/Pinworm treatment in pregnancy. Date of issue:January 2018, Version: 2.

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

Tonsillitis

When to treat

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. Antibiotic NNT greater than 4000 to prevent one case of quinsy.

 

Optimise management of pain - regular paracetamol or ibuprofen for pain (right dose for age or weight at the right time and maximum doses for severe pain).1,2

Base decision about antibiotic treatment on FeverPAIN1,2 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: 13-18% likelihood of isolating streptococcus: use NO antibiotics
  • Score 2-3: 34-40% likelihood of isolating streptococcus, use back up/delayed antibiotic OR NO antibiotic
  • Score 4 or more: 62-65% likelihood of isolating streptococcus, use immediate antibiotic OR back-up antibiotic

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).

When to investigate

Most children with tonsillitis do not require a throat swab.

Safety netting

Provide verbal and written advice

 

Treatment choices

For children unable to swallow tablets

Amoxicillin for 7 days

40mg/kg po BD (max 1g per dose) (off-label)

Or by age:

3-11 months: 125mg po TDS3 or 250mg po BD4 (off-label)

1-4 years: 250mg po TDS3 or 500mg po BD4 (off-label)

5-11 years: 500mg po TDS3 or 750mg po BD4 (off-label)

12 years and over: 500mg po TDS3 or 1g po BD4 (off-label)  

 OR 

Phenoxymethylpenicillin (Penicillin V)1 for 7 days

1-11 months: 125 mg po BD

1-5 years: 250 mg po BD

6-11 years: 500 mg po BD

12-17 years: 1g po BD

For children able to swallow tablets

Phenoxymethylpenicillin (Penicillin V)1 for 7 days

6-11 years: 500 mg po BD

12 years or over: 1g po BD

 

If allergic to penicillin

Clarithromycin1 for 5 days

Weight-based for 1 month to 11 years:

Under 8 kg: 7.5mg/kg po BD

8-11 kg: 62.5mg po BD

12-19 kg: 125mg po BD

20-29 kg: 187.5mg po BD

30-40 kg: 250mg po BD

12 - 17 years: 500mg po BD

OR

 Erythromycin for 5 days

1-23 months: 250mg po BD3

2-7 years: 500mg po BD3

8-17 years: 1g po BD1,3 

 

Cautions

  • Aim to use an antibiotic that minimises dosing frequency and is palatable (if suspension prescribed) to optimise adherence. Phenoxymethylpenicillin (penicillin V) and flucloxacillin suspensions given QDS are not well tolerated by children.
  • 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 emerging data to suggest that the use of amoxicillin does not significantly increase the risk of rash in acute EBV – see LINK. In addition, data suggests that EBV accounts for as little as 1% of tonsillitis presenting to doctors - see LINK and more importantly, EBV is extremely rare in children below 12 years of age. For this reason, the current recommendation is to use amoxicillin suspension in young children (palatability) and phenoxymethylpenicillin (penicillin V) tablets for children able to swallow tablets (due to higher rates of EBV in this age group).

References

  1. NICE NG84, Sore throat (acute): antimicrobial prescribing. 01/18 LINK date accessed 11/21
  2. NICE & PHE. Summary of antimicrobial prescribing guidance – managing common infections LINK accessed 11/21
  3. BNFc accessed at LINK 11/21
  4. WHO - Recommendations for management of common childhood 2012 conditions. LINK accessed 11/21
  5. Spinks A et al. Antibiotics for sore throat. Cochrane Database Syst Rev. 2013; (11): CD000023. LINK
  6. Little P et al. Open randomised trial of prescribing strategies in managing sore throat. BMJ. 1997; 314(7082): 722-7. LINK
  7. Little P et al. Predictors of suppurative complications for acute sore throat in primary care: prospective clinical cohort study. BMJ. 2013; 347: f6867 LINK

 

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

Click here for tips for antibiotic prescribing in children and the evidence base supporting them

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

 

Last updated

March 2022

Urinary Tract Infection

When to treat:

  • Child under 3 months with temp 38°C or greater, or age 3 months or older and haemodynamically unstable: refer URGENTLY to secondary care for assessment.
  • Consider UTI in any sick child and every young child with unexplained fever. Consider differential diagnoses: sepsis, meningitis, GI obstruction, appendicitis, gastroenteritis. Other differentials for dysuria/discomfort include vulvovaginitis and threadworms.
  • UTIs in children require prompt treatment to minimise the risk of renal scarring.
  • If UTI suspected but systemically well and apyrexial, suggestive of lower UTI.
  • If upper UTI suspected (fever with or without symptoms of pyelonephritis), and urine nitrites and/or leukocytes positive, send urine for culture and start empirical treatment. Provide family with UTI safety netting information.
  • Imaging: only refer if child under 6 months, recurrent or atypical UTI.

When to investigate

Whenever possible a specimen of urine should be collected for culture and sensitivity testing before starting antibacterial therapy – clean catch if possible. See Healthier Together UTI pathway for information about when to send urine for culture or what to do if UTI suspected but unable to collect a urine specimen. (Image below)

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

For toilet trained children send correctly performed midstream clean catch urine sample. Provide clear instructions to parents/carers.

Safety netting

Provide written and verbal advice

 

Treatment choices

If unable to tolerate oral antibiotics or systemically unwell (suggestive of bacteraemia) or child under 3 months old:

Requires URGENT review in hospital for consideration of IV antibiotics – call paediatrician.

 

Over 3 months of age with LOWER UTI/cystitis

Duration of antibiotic course: 3 days

Trimethoprim (if low risk of resistance)1,2

3-5 months: 4mg/kg po BD (max 200mg per dose) or 25mg po BD1

6 months-5 years: 4mg/kg po BD (max 200mg per dose) or 50mg po BD1

6-11 years: 4mg/kg po BD (max 200mg per dose) or 100mg po BD1

12-15 years: 200mg po BD1

OR

Nitrofurantoin1,2 (Only if child can swallow tablets, previous treatment with trimethoprim in preceding 3 months and eGFR 45ml/min/1.73m2 and over):

3 months-11 years: 750 micrograms/kg po QDS (use immediate release tablets)1

12-17 years: 100mg MR po BD1

OR

Cefalexin – all doses off label2

12.5mg/kg (max 1g per dose) po BD

Or by age:

3-11 months: 125mg po BD1

1-4 years: 125mg po TDS1

5-11 years: 250mg po TDS1

12-15 years: 500mg po BD1 

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

Ciprofloxacin 10mg/kg po BD (double dose in severe infection) (max 750mg po BD)3

 

Over 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

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

Cefalexin - all doses off label

12.5mg/kg (max 1g per dose) TDS

or by age:

3-11 months 125mg po TDS

1- 4 years 250mg po TDS

5-11 years 500mg po TDS

12 years and over 1g po TDS

 

If confirmed severe penicillin allergy, sensitivities are not known

Ciprofloxacin 10mg/kg po BD (double dose in severe infection) (max 750mg po BD)3

 

Preventing recurrence

  • Address dysfunctional elimination syndromes and constipation
  • Encourage children to drink an adequate amount
  • Emphasize the importance of not delaying voiding. Children should have ready access to clean toilets

 

Cautions

  • Aim to use an antibiotic that minimises dosing frequency and is palatable (if suspension prescribed) to optimise adherence.
  • Risk factors for recurrent UTIs:
    • Constipation
    • Poor fluid intake
    • Infrequent voiding especially at school (holding on)
    • Irritable bladder (can happen following UTI)
    • Neuropathic bladder
      • Examine spine
    • Genitourinary abnormalities
      • Examine genitalia

Evidence

  • This guideline cites a range of studies that suggest that all infants and children who have bacteriuria and either fever of 38°C or higher, or loin pain/tenderness, should be considered to have acute pyelonephritis/upper urinary tract infection. All other infants and children who have bacteriuria, but no systemic symptoms or signs, should be considered to have cystitis/lower urinary tract infection.  Findings indicated that shorter courses of antibiotics (7 to 10 days) improved compliance, decreased antibiotic-related adverse events, and diminished the emergence of resistant organisms. Antibiotics with low local resistance patterns have therefore been chosen.
  • Nitrofurantoin should be avoided in patients with an estimated glomerular filtration rate (eGFR) of less than 45ml/min but may be used with caution in certain patients if potential benefit outweighs risk with an eGFR of 30 to 44 ml/min/1.73m2 if a short course (max 7 days) is prescribed.3,5

References

  1. NICE (2018). Urinary tract infection (lower):antimicrobial prescribing 2018 LINK accessed 12/21
  2. NICE & PHE. Summary of antimicrobial prescribing guidance – managing common infections LINK accessed 12/21
  3. BNFc accessed at LINK  in 12/21
  4. NICE NG111 Pyelonephritis (Acute):antimicrobial prescribing 10/18  LINK
  5. MHRA 2015. Accessed 12/21 LINK
  6. PHE. Diagnosis of urinary tract infections. Quick reference tool for primary care for consultation and local adaptation. April 2019. Accessed at LINK August 2019
  7. Strohmeier Y et al. Antibiotics for acute pyelonephritis in children. Cochrane Database Syst Rev. 2014; 7
  8. Michael M et al. Short versus standard duration oral antibiotic therapy for acute urinary tract infection in children. Cochrane Database Syst Rev. 2003;(1):CD003966.

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

Click here for tips for antibiotic prescribing in children and the evidence base supporting them

Last updated

March 2022

 

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