Hospital Empirical Antibiotic Therapy in Children

Antimicrobial prescribing: NHS Borders
NHS Borders

Hospital Empirical Antibiotic Therapy in Children

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 at https://www.rightdecisions.scot.nhs.uk/antimicrobial-prescribing-nhs-borders/adult-hospital-guidance/penicillin-allergy/    

See East Region Formulary “Infections” https://formulary.nhs.scot/east/infections  for information on managing common infections

Doses of antibiotics are as recommended in the BNF for Children.

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 possible encephalitis consider adding IV Aciclovir

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

If true penicillin allergy consult Paediatrician or Microbiology for advice.

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

Hospital Acquired

Discuss with Paediatrician/ Microbiology

Respiratory

1Azithromycin/clarithromycin numerous serious drug interactions, see BNFc or contact Pharmacy for details.

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

Under 5 years
Oral Amoxicillin
Duration 5 days
or if true penicillin allergy
oral Azithromycin1
Duration 3 days

5 years and above or mycoplasma or Chlamydia likely pathogen
Oral Azithromycin1
Duration 3 days

Severe CAP

IV Co-amoxiclav
+
IV Clarithromycin1

If septic consider adding
IV Gentamicin

Penicillin allergy

Seek advice from Microbiology if history of immediate hypersensitivity

Aspiration pneumonia

IV Co-amoxiclav
Or if true penicillin allergy
IV Clindamycin (or oral if route available)

 

Pertussis

Oral Clarithromycin1

See UKHSA guidance

Duration 7 days

And inform Public Health.

Ear, Nose and Oropharynx

1Azithromycin/clarithromycin numerous serious drug interactions, see BNFc or contact Pharmacy for details.

Tonsilitis

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

Or if true penicillin allergy
Clarithromycin1
Duration 5 days

 

Otitis media

See East Region Formulary

 

Otitis Externa

See East Region Formulary

 

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

See East Region Formulary

 

Candida (oral)

See East Region Formulary

Urinary tract

2Ceftriaxone
In neonates see Cautions/contra-indications in BNF for Children - an alternative is Cefotaxime. 

If higher dose of Cefriaxone2 indicated in very severe infections see BNF dosing.

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

Upper tract UTI/pyelonephritis

Fever above 38°C and significant systemic upset or if patient below 3 months of age
IV Ceftriaxone2
(consider stat dose of Gentamicin if severely unwell)


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

See East Region Formulary

Bone/joint infection

Septic arthritis/osteomyelitis

5 years and under
IV Cefotaxime
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

1Azithromycin/clarithromycin numerous serious drug interactions, see BNFc or contact Pharmacy for details

Cellulitis

IV Flucloxacillin
Switching to oral Flucloxacillin

or if true penicillin allergy
Non severe illness:
oral/IV Clarithromycin1
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 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
oral Metronidazole + oral Co-trimoxazole

And see East Region Formulary for further guidance

 

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 – oral Clarithromycin1


Duration 5 days then review.

Eyes

Conjunctivitis

1st line:
No treatment


2nd line:
Chloramphenicol
Drops/ointment

And see East Region Formulary for further guidance

Editorial Information

Last reviewed: 31/05/2026

Next review date: 31/05/2029

Author(s): Duguid, A.

Version: 4.0

Co-Author(s): James, E, Longworth, E, Taylor, J, McNeil, A.

Approved By: NHS Borders Antimicrobial Management Team

Reviewer name(s): Duguid, A.