User guide

Good practice hints & tips
• Stop and think before you give antibiotics. Prescribe an antibiotic only when there is likely to be a clear clinical benefit
• Avoid broad spectrum antibiotics where a narrow spectrum agent will be effective
• Document indication and stop/review date in patient notes
• Review previous microbiology results: If resistant target organisms previously isolated (e.g. MRSA, ESBL, known resistance to empirical antibiotic choices), discuss antibiotic choice with Paediatric and/or Microbiology Consultant.

Review antibiotic therapy daily
• Stop?
• Switch? When clinically reasonable, consider switching from IV to oral
• Simplify? Review/rationalise antibiotics and change to narrow spectrum once microbiology results are available.
• State duration

Is your patient ready for IVOST?
• Clinical Improvement in signs of infection e.g. resolving sepsis, reduction in PEWS score, improvement of infection markers e.g. WCC and CRP (CRP does not always reflect severity of illness or the need for IV antibiotics and may remain elevated as the infection improves. Do not use CRP in isolation to assess whether someone is suitable for IVOST.
• Oral Route is available and no concerns regarding absorption
• Uncomplicated infection. Certain infections need prolonged IV therapy e.g. meningitis, encephalitis, cystic fibrosis, endocarditis, bone and joint infection, undrainable deep abscess, bacteraemia, infected prosthetic devices. For these indications, seek Microbiology / Paediatric Infectious Diseases advice for antibiotic / oral switch plan.

If all above criteria are met:
• Can you STOP antibiotics? e.g. alternative diagnosis 
• If not, then SWITCH TO ORAL.

Switching to oral antibiotics
• Are there any positive microbiology results? Can you narrow the spectrum based on culture results?
• Are microbiology results negative (or pending)? Use empirical oral switch choice, as listed. 

• Most infections require ≤7 days total (IV + PO) of antibiotics.
• Record the intended duration in the notes, and add a stop date to HEPMA.
• Further advice available from Microbiology, if required.

If the patient is penicillin allergic, review the nature of the allergy.
• If allergy is minor (e.g. rash), it is safe to use cephalosporins (cross-over sensitivity is less than 10%). 
• If allergy is major (e.g. anaphylaxis), do not use beta-lactam antibiotics (e.g. amoxicillin, co-amoxiclav, tazocin) or cephalosporins (e.g. cefotaxime, ceftriaxone). If a penicillin allergy alternative is not given in this policy then contact microbiology for further advice.

Dose as recommended in BNF for Children 
• https://bnfc.nice.org.uk/
• Doses may need to be adjusted in renal/liver impairment.

Dosing for isolates reported as "I"
 • Refer to guideline from NHS Greater Glasgow & Clyde.

Gentamicin / vancomycin dosing  
• Refer to appendix 1

Further dosing advice can be obtained through Pharmacy.

Ceftriaxone
• See cautions/contra-indications in BNFc
• Ceftriaxone is contraindicated in premature neonates up to a postmenstrual age of 41 weeks (gestational age+ chronological age) or full term neonates with hyperbilirubinaemia, jaundice or who are hypoalbuminaemic or acidotic because these conditions in which bilirubin binding is likely to be impaired leading to risk of bilirubin encephalopathy.
• Cefotaxime is an alternative to ceftriaxone in neonates.
• Higher dose ceftriaxone is indicated in very severe infections

Drug interactions
• Always check BNFc for interactions when prescribing
• Ciprofloxacin/macrolides are high risk for interactions
• Quinolones have decreased absorption with iron, calcium, magnesium and some nutritional supplements. See BNFc or pharmacy for advice.