Empirical antibiotic therapy in children

What's new / Latest updates

Addition/amendments May 2022:

Removal of Covid indication
Addition of Acute Mastoiditis indication
UTI: change to referral age cut off & oral agent
Bone and Joint: removal of sodium fusidate
Addition of link to penicillin allergy advice
Change to severe CAP

This guideline is intended to guide medical staff in the choice of appropriate antibiotic treatment of infections.
The initial treatment may need to be modified according to clinical response and results of microbiology and other investigations.
The appropriate specimens for microbiology should be taken whenever possible before administering antibiotics, however this will depend upon the severity of the illness
and the nature of the specimen. In patients who are stable and not septic, and in whom infection is only one of a number of possibilities, consideration should be given to
deferring antibiotics until the results of cultures are known, as long as there is no change in the clinical condition in the interim.
The need for antibiotics and their route of administration should be reviewed daily.
A definite decision regarding treatment should be taken at 2 and 5 days.
When clinically reasonable, consider changing from IV to oral therapy.
Seek specialist advice if infection suspected in immuno-compromised patients. General advice on Penicillin allergy can be found here.
Doses of antibiotics are as recommended in the BNF for Children.

RATIONALISE ANTIBIOTIC THERAPY when microbiology results become available or clinical condition changes.
Further advice can be obtained from the Consultant Microbiologist (Bleep 6231) or Consultant Paediatrician. Infection Control advice may be given by the Consultant Microbiologist

CNS infection

Bacterial Meningitis

Always refer to senior staff.

Under 6 weeks (Steroids are not of proven benefit in this age group)
IV Cefotaxime+
IV Amoxicillin +
IV Gentamicin

6 weeks to 3 months (Steroids are not of proven benefit in this
age group).
IV Cefotaxime

Older than 3 months
IV Cefotaxime
From 3 months, add Dexamethasone (duration 4 days), if
bacterial meningitis without purpura.

If true penicillin allergy consult Paediatrician or Microbiology for advice.

Seek Paediatrician/microbiology advice.
Inform Public Health to discuss possible prophylaxis and contact
tracing.

Septicaemia of unknown origin

Septic Neonate – community acquired

Early onset
<72 hours of age
IV Benzylpenicillin
+
IV Gentamicin

Late onset
>72 hours of age
IV Cefotaxime +
IV Amoxicillin +
IV Gentamicin
and see neonatal unit guidelines

1 month and above – Community Acquired

IV Cefotaxime+
IV Gentamicin if severe

If meningitis cannot be excluded consider adding IV Amoxicilin for listeria cover up to 6 weeks of age.

1 month and above – Hospital Acquired

IV Piperacillin/Tazobactam
+
IV Gentamicin
If true penicillin allergy: consult Microbiology for advice.

Lower respiratory tract

Non-severe community-acquired pneumonia (CAP) (Non neonatal)

Under 5 years
Oral Amoxicillin
Duration 5 days
or if true penicillin allergy
oral Azithromycin
Duration 3 days

5 years and above or mycoplasma or Chlamydia likely pathogen
Oral Azithromycin
Duration 3 days

Severe CAP

IV Cefotaxime
+
IV Clarithromycin

If septic consider adding
IV Gentamicin

Aspiration pneumonia

IV Co-amoxiclav
Or if true penicillin allergy
IV Clindamycin

Upper respiratory tract

Tonsilitis

First Line:
No antibiotics
Second Line:
Oral Penicillin V
Duration 5-10 days

Or if true penicillin allergy
Clarithromycin
Duration 5 days

Pertussis

Oral Clarithromycin
Duration 7 days
And inform Public Health

Otitis media

Children with acute otitis media should not be routinely prescribed antibiotics. Consider delayed antibiotic treatment.
Oral Amoxicillin
or if true penicillin allergy
oral Clarithromycin
Duration 5 days

Acute mastoiditis

Seek ENT advice
IV Cefotaxime
+
IV Metronidazole

Gastro-intestinal

Gastro-enteritis

No antibiotic usually required

Intra-abdominal sepsis

IV Cefotaxime
+
IV Metronidazole

If true beta-lactam
allergy
IV Clindamycin
+
IV Gentamicin

H pylori

Discuss with Paediatrician before treatment

Threadworms

>6 months
Mebendazole

<6 months seek advice

Note: mebendazole not licensed in children <2 years of age

Candida (oral)

Nystatin

Urinary tract

Refer to Paediatrician if child is under 3 months of age/ or severely unwell.

Upper tract UTI/pyelonephritis or with systemic upset

●Fever above 38°C and significant systemic upset or if patient below 3 months of age
IV Ceftriaxone*
+/-
IV Gentamicin
If true penicillin allergy use Gentamicin initially and discuss with
Microbiology.

●Fever above 38°C and mild systemic upset in patients above 3 months of age
Oral cefalexin
If true penicillin allergy discuss with Microbiology.

3 months or older with lower tract UTI/cystitis with no systemic upset

Oral Cefalexin

Ceftriaxone*
In neonates see Cautions/contra-indications in BNF for Children - an alternative is Cefotaxime

If higher dose of Cefriaxone* indicated in very severe infections see BNF dosing.

Bone/joint infection

Septic arthritis/osteomyelitis

5 years and under
IV Cefuroxime
Switching to oral co-amoxiclav
If true penicillin allergy: Discuss with Microbiology

6 years and above -
IV Flucloxacillin
Switching to oral co-amoxiclav liquid or
flucloxacillin capsules

If true penicillin allergy
IV Clindamycin and
discuss with
Microbiology.
Switching to oral clindamycin

If incomplete HIB immunisation then use
IV Co-amoxiclav

Skin/soft tissue

Cellulitis

IV Flucloxacillin
Switching to oral Flucloxacillin

or if true penicillin allergy
Non severe illness:
IV Clarithromycin
Severe illness:
IV Vancomycin

If severe sepsis or incomplete HIB immunisation add gentamicin to above.

Duration 5-14 days (longer courses may be required.)

Orbital or periorbital cellulitis

Refer to ENT/opthalmology
IV Flucloxacillin + IV Cefotaxime
(+ IV Metronidazole if no clinical improvement after 24-36h)
If true penicillin allergy
IV clindamycin
+IV gentamicin

Human/animal bite

Co-amoxiclav
Or if true penicillin allergy
Human bite Metronidazole + Clarithromycin
Animal Bite – Metronidazole + Co-trimoxazole
Duration 5- 7 days

3 days of prophylactic antibiotics should be given to all moderate/severe bites especially if oedema, crush, puncture wounds, facial, genital, hand or foot bites or immuno-compromised hosts.
Consider tetanus prophylaxis and, for human bites, blood borne
virus transmission. Consider rabies if animal bite acquired in endemic area.

Impetigo

Topical fusidic acid, consider topical if only small areas of very localised lesions after checking with Microbiology

Oral Flucloxacillin if widespread.

If true penicillin allergy – Clarithromycin
Duration 5 days then review.

Eyes

Conjunctivitis

1st line:
No treatment
2nd line:
Chloramphenicol
Drops/ointment

Miscellaneous

Athlete's foot

topical clotrimazole

Candida (perineal)