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  6. Antibiotic Therapy in Children: Empirical Recommendations (1288)

Antibiotic Therapy in Children: Empirical Recommendations (1288)

This policy is intended to guide prescribers on appropriate treatment of infections in children at the Royal Hospital for Children, Glasgow.

For antibiotic guidance for children in primary care in NHSGGC see Empiric infection management, Primary Care, Paediatric (227)

Please also consult local unit guidance, including for patients in the Haematology/Oncology Ward (Schiehallion), the Paediatric Intensive Care Unit (PICU) and the Neonatal Intensive Care Unit (NICU). In patients with complex co-morbidities, check for an existing antimicrobial plan.

General Principles

Starting antibiotics

Appropriate specimens for culture (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 several possibilities, consideration should be given to deferring antibiotics until the results of cultures are known if there is no change in the clinical condition in the interim. 

If patients are known to be colonised with or have previously cultured MRSA or other multi-drug-resistant organisms, discuss antibiotic management with a Consultant Microbiologist or Consultant in Paediatric Infectious Diseases.

Antibiotic dosing

Doses of antibiotics are recommended in the BNF for Children (BNFc). Dose according to the clinical indication. Caution should be applied in renal/liver impairment. For dose adjustments see the BNFc or contact a Paediatric Pharmacist for advice. Add a ‘Clinical indication’ when prescribing on electronic/paper drug charts. Add a ‘Stop date’ where possible.

In children where isolates are reported as ‘I’ on culture (microbiology) this indicates that a specific dosing schedule is required for the antibiotic to effectively treat the infecting organism. See the Paediatric Isolate guidance for further information.

Gentamicin should not continue beyond 3 doses, discuss with the Infectious Diseases (ID)/Microbiology teams if a prolonged course of IV antibiotics is required. If prescribed empirical cefotaxime, consider switching IV cefotaxime to IV ceftriaxone when the patient is stable with clinical improvement. See cautions/contraindications for ceftriaxone in neonates in the BNFc.

IV to Oral Switch Therapy (IVOST)

The need for antibiotics and their route of administration should be reviewed daily. Some antibiotics have high oral bioavailability and the IV route should only be used if patients are unable to take oral medications. Metronidazole, clindamycin and co-trimoxazole have over 90% oral bioavailability, ciprofloxacin has 70 – 80% oral bioavailability.  Please be aware that oral liquid clindamycin may be difficult to obtain from community pharmacies and may need to be prescribed and dispensed from the hospital.

Antibiotics should be rationalised when culture (microbiology) results become available at 48 to 72 hours. When clinically reasonable, consider changing from intravenous (IV) to oral therapy. Refer to the Paediatric IV to oral switch therapy (IVOST) guidance. In patients who are clinically stable, but who can’t be switched to oral antibiotics, consider referral to the Out-patient Parenteral Antibiotic Therapy (OPAT) Service for completion of therapy. 

Further advice

Further advice on antimicrobial prescribing can be obtained from a Consultant Microbiologist, a Consultant in Paediatric Infectious Diseases or the Paediatric Antimicrobial Pharmacist. Infection control advice may be given by a Consultant Microbiologist or the Infection Prevention and Control team. 

Penicillin allergy

Drug allergy refers to immunologically mediated drug hypersensitivity reactions. These may be either immediate (IgE-mediated) or non-immediate (non-IgG mediated) reactions. Most non-IgE mediated are type 4 T-cell mediated reactions.  

Approach 

Take a detailed drug allergy history, review the patient’s clinical records, including alerts, and prior prescriptions.  

Presentation

In IgE-mediated reactions symptoms typically develop within 1 hour of drug administration. Reactions can occur days or weeks into a course of treatment. Patients may present with urticaria, angioedema (oedema of the skin or mucous membranes, commonly lips and eyelids), conjunctivitis, rhinitis, bronchospasm, nausea, vomiting and diarrhoea. Patients may progress rapidly to anaphylaxis, with cardiorespiratory compromise.  

Non-IgE-mediated reactions classically present with a symmetrical maculopapular rash sparing the palms and soles. This is often within 6 to 10 days after the first drug exposure, or within 3 days of the second drug exposure, but can occur before these times. Non-IgE mediated reactions can also present as severe reactions with systemic involvement, with mucosal changes (Steven-Johnson's syndrome (SJS), toxic epidermal necrolysis (TEN), and drug-related eosinophilia with systemic symptoms (DRESS)). 

History not consistent with penicillin allergy  

Children with the following have no increased risk of an allergic reaction on re-exposure, and the penicillin allergy label can be removed (patient delabelled) 

  • A family history but no personal history of penicillin allergy (this is not a risk factor for penicillin allergy).  
  • The patient has taken and tolerated (no reaction) the same penicillin after the reported reaction.  
  • Symptoms that reflect dose-related reactions rather than antibiotic allergy 
  • Minor gastrointestinal symptoms e.g. nausea, abdominal pain, diarrhoea 
  • Oral thrush (Candidiasis) 
  • Headache, arthralgia, strange taste in mouth 

Penicillin allergy 

If the history is consistent with drug allergy, document this in the clinical records and on the patient prescription. Treat the patient with the penicillin allergy recommendation.  

Avoid β-lactam antibiotics (including penicillin V/phenoxymethylpenicillin, amoxicillin, co-amoxiclav, flucloxacillin, piperacillin-tazobactam (Tazocin) and first generation cephalosporins (including cephalexin).

Second and third generation cephalosporins (including cefuroxime, cefotaxime and ceftriaxone), carbapenems (including meropenem) and monobactams (aztreonam) can be used with caution in an emergency or in patients with severe infections if there is no recommended alternative and no history of an immediate (IgE-mediated) allergy including anaphylaxis, or a severe non-IgE-mediated allergy (including SJS, TEN and DRESS) to penicillin.  If prescribed, the patient should be monitored closely after administration. 

Examples of antibiotics that are safe in penicillin allergy

Tetracyclines (e.g. doxycycline), aminoglycosides (e.g. gentamicin), macrolides (e.g. clarithromycin, azithromycin, erythromycin), quinolones (e.g. ciprofloxacin, levofloxacin), glycopeptides (e.g. vancomycin, teicoplanin), trimethoprim, co-trimoxazole, metronidazole, clindamycin and linezolid. This is not an exhaustive list. 

Drug allergy clinic

Discuss referral to the drug allergy clinic with the Paediatric Infectious Diseases, Immunology or Allergy team. If indicated, dictate a referral letter to the drug allergy clinic.

Central Nervous System (CNS) Infection

Bacterial Meningitis

Encephalitis

Cerebral Abscess/Subdural Empyema 

Cerebral Venous Sinus Thrombosis

CSF Shunt Infection 

 

Bacterial Meningitis

Always refer to senior staff to perform an initial assessment to ensure that:

  1. Intravenous antibiotics are started as soon as bacterial meningitis is suspected, within 1 hour of arrival in hospital.
  2. Unless contraindicated, lumbar puncture is performed before starting antibiotics.

Seek ID/microbiology advice about every case of confirmed bacterial meningitis. 

For suspected meningococcal infection inform the NHS GGC Public Health Protection Team on 64917 Mon-Fri 9-5pm, or via the RHC hospital switchboard and ask for the on-call team out of hours, to discuss contact tracing and antibiotic prophylaxis.

Treatment:

For suspected bacterial meningitis when the causative organism has not been identified (whilst awaiting test results):

  1. Age < 1 month IV Cefotaxime*+ IV Gentamicin** + IV Amoxicillin (Use IV Amoxicillin dose in BNFc for Listeria Meningitis, stop if cultures do not grow Listeria spp. after 48 hours). 

  2. Age 1 month and above IV Cefotaxime*

Dexamethasone:

For children over 3 months with strongly suspected or confirmed bacterial meningitis, give intravenous dexamethasone.

For babies between 28 days and 3 months old with strongly suspected or confirmed bacterial meningitis, discuss with ID.

When the causative organism is found:

  • continue dexamethasone if it is pneumococcus or Haemophilus influenzae type b
  • stop dexamethasone for all other organisms.

If no causative organism is found, discuss with ID on whether or not to continue dexamethasone.

For children receiving dexamethasone:

  • give the first dose with or before the first dose of antibiotics if possible
  • however, do not delay antibiotics to wait for dexamethasone to be started
  • if dexamethasone is delayed for less than 12 hours after the start of antibiotics, give dexamethasone as soon as possible
  • if dexamethasone is delayed for more than 12 hours after the start of antibiotics, discuss with ID to decide whether dexamethasone is still likely to provide benefit.

If true penicillin allergy: Consult ID/Microbiology for advice.

Rationalise antibiotic choice according to results of CSF studies (CSF culture, bacterial & viral PCR). If multi-drug-resistant bacteria are identified consult ID/Microbiology.

*Consider switching IV cefotaxime to IV ceftriaxone when stable and clinical improvement. A higher dose of ceftriaxone is indicated for meningitis - see BNFc for dosing. See cautions/contraindications for ceftriaxone in neonates in the BNFc.

**Gentamicin should not continue beyond 3 doses, discuss with ID/Microbiology if a prolonged course of intravenous antibiotics is required. 

Duration:

If bacterial meningitis is suspected but the causative organism is unknown (CSF culture & PCR testing negative), continue IV antibiotics for 10 days.  If under 3 months of age, consider treating with IV antibiotics for 14 days. Discuss with ID/Microbiology if required.

When the causative organism is known, minimum duration IV antibiotics as below. If ongoing clinical concerns on completion of treatment course, discuss with ID/Microbiology.

Streptococcus pneumoniae: 10 days

Haemophilus influenzae type B: 7-10 days

Group B streptococcus: 14 days

Enterobacterales (coliforms) e.g. E. coli: 21 days

Listeria monocytogenes: 21 days. Discuss with ID/Microbiology  

Neisseria meningitidis: 5 days  

Treatment Notes

  1. Treatment is all with IV antibiotics. PO antibiotic therapy is not appropriate to treat CNS infection.
  2. Consider Tuberculosis (TB) meningitis if risk factors for TB infection. Typical CSF findings in TB meningitis include very high protein, low glucose and raised CSF WCC count (predominantly lymphocytes). Any child in whom TB meningitis is considered should be discussed with the ID team immediately.
  3. Consider Herpes Simplex Virus (HSV) meningoencephalitis in infants < 1 month of age. Common features of HSV disease include presentation with sepsis in the first 2 weeks of life (median age 8 days), encephalopathy, seizures, fever, vesicles (>70% infants with HSV disease have no skin, eye or mouth lesions), raised ALT/AST, coagulopathy. Consider if recent maternal HSV disease but note that around 80% infants with HSV disease are born to women with no history of genital herpes. See the BPSU study. In older children consider HSV disease if focal seizures and encephalopathy. Send EDTA blood and CSF for HSV PCR. See section on Encephalitis.

Encephalitis

Consider Herpes Simplex Virus (HSV) meningoencephalitis in infants < 1 month of age.

Common features of HSV disease include presentation with sepsis in the first 2 weeks of life (median age 8 days), encephalopathy, seizures, fever, vesicles (>70% infants with HSV disease have no skin, eye or mouth lesions), raised ALT/AST, coagulopathy. Consider if recent maternal HSV disease but note that around 80% infants with HSV disease are born to women with no history of genital herpes. See the BPSU study.

For older children consider HSV disease if focal seizures and encephalopathy.

Send EDTA blood and CSF for HSV PCR.

If high suspicion of HSV encephalitis and initial CSF HSV PCR is negative, CSF HSV PCR testing should be repeated over 72 hours into illness.

Treatment:

IV Aciclovir (ensure adequate hydration)

Duration:

If confirmed HSV in CSF, repeat LP after minimum duration of: 

  • 21 days (immunocompromised or age <12 years)
  • 14 days (immunocompetent and age >=12 years)

If LP positive, continue aciclovir for a further 7 days then repeat LP. If remains positive after 21 days/28 days, discuss with ID/virology. 

Following neonatal HSV infection - PO aciclovir prophylaxis for 6 months.

Cerebral Abscess/Subdural Empyema 

Discuss all cases with ID/Microbiology. 

Treatment:

IV Cefotaxime* + IV/PO Metronidazole

If true penicillin allergy:  IV Vancomycin + IV/PO Ciprofloxacin** + IV/PO Metronidazole

*Consider switching IV cefotaxime to IV ceftriaxone when stable and clinical improvement. A higher dose of ceftriaxone is indicated for CNS disease - see BNFc dosing recommendation for severe infection/bacterial meningitis. See cautions/contraindications for ceftriaxone in neonates in the BNFc.

**Please see MHRA alert on fluoroquinolone antibiotics.

Duration:

Minimum 6 weeks for aspirated or conservatively treated brain abscess & subdural empyema. Minimum 4 weeks for excised brain abscess.

Stop metronidazole after a total of 4 weeks.

Cerebral Venous Sinus Thrombosis

Refer to Cerebral venous sinus thrombosis guideline for further details on management.

Discuss all cases with ID/Microbiology.

Treatment:

IV Cefotaxime* + IV/PO Metronidazole

If true penicillin allergy: IV Vancomycin + IV/PO Ciprofloxacin** + IV/PO Metronidazole 

*Consider switching IV cefotaxime to IV ceftriaxone when stable and clinical improvement. A higher dose of ceftriaxone is indicated for CNS disease - see BNFc dosing recommendation for severe infection/bacterial meningitis. See cautions/contraindications for ceftriaxone in neonates in the BNFc.

**Please see MHRA alert on fluoroquinolone antibiotics

Duration:

Minimum 3 weeks for extradural infection & minimum 6 weeks for subdural infection.

Stop metronidazole after a total of 4 weeks.

CSF Shunt Infection 

Discuss all cases with ID/Microbiology.

Treatment

Patient must be fasted and discussed with neurosurgery urgently for consideration of removal of VP shunt.

IV Cefotaxime* + IV Vancomycin

If true penicillin allergy: IV Meropenem & IV Vancomycin 

*Consider switching IV cefotaxime to IV ceftriaxone when stable and clinical improvement. A higher dose of ceftriaxone is indicated for CNS disease - see BNFc dosing recommendation for severe infection/bacterial meningitis. See cautions/contraindications for ceftriaxone in neonates in the BNFc.

Duration:

10 – 14 days if shunt removed.

Immunocompromised Patient

Immunocompromised plus Sepsis

Refer to Management of neutropenia and fever: antibiotic policy if patient is known to the Haematology / Oncology team and discuss with the on-call team. For immunocompromised / immunosuppressed patients known to other hospital specialties see documented individualised plan or discuss with the primary team.

For previously unknown patients with febrile neutropenic sepsis:

Treatment:

IV Piperacillin/Tazobactam + IV Gentamicin*  

If Staphylococcal infection is suspected (e.g. line-related sepsis or soft tissue infection) ADD IV Vancomycin.

If true penicillin allergy: IV Vancomycin + IV Gentamicin*

*Gentamicin should not continue beyond 3 doses, discuss with ID/Microbiology if a prolonged course of intravenous antibiotics is required. 

Duration on advice from ID/Microbiology.

Sepsis of Unknown Origin

Community-acquired

Hospital-acquired

Suspected iGAS sepsis/Toxic Shock Syndrome

Community-acquired

For suspected meningococcal infection Inform the NHS GGC Public Health Protection Team on 64917 Mon-Fri 9-5pm, or via the hospital switchboard and ask for the on-call team out of hours, to discuss contact tracing and antibiotic prophylaxis.

Treatment:

  1. Age < 1 month

IV Cefotaxime* + IV Gentamicin** + IV Amoxicillin (Use IV Amoxicillin dose in BNFc for Listeria Meningitis, stop if cultures do not grow Listeria spp. after 48 hours). 

Consider Herpes Simplex Virus (HSV) in infants < 1 month of age. Common features of HSV disease include presentation with sepsis in the first 2 weeks of life (median age 8 days), encephalopathy, seizures, fever, vesicles (>70% infants with HSV disease have no skin, eye or mouth lesions), raised ALT/AST, coagulopathy. Consider if recent maternal HSV disease but note that around 80% infants with HSV disease are born to women with no history of HSV. See the BPSU study.  Send EDTA blood and CSF for HSV PCR. See section on Encephalitis. Start IV aciclovir if any concern of disseminated HSV.

If true penicillin allergy: Consult ID/Microbiology for advice.

  1. Age 1 month and above

IV Cefotaxime* + consider addition of IV Gentamicin** if severe 

If true penicillin allergy: Consult ID/Microbiology for advice.

*Consider switching IV cefotaxime to IV ceftriaxone when stable and clinical improvement. See BNFc dosing recommendation. See cautions/contraindications for ceftriaxone in neonates in the BNFc.

**Gentamicin should not continue beyond 3 doses, discuss with ID/Microbiology if a prolonged course of intravenous antibiotics is required. 

Duration (for all ages):

When the causative organism is known, minimum duration IV antibiotics as below. If ongoing clinical concerns on completion of treatment course, discuss with ID/Microbiology. If diagnosed with bacteraemia and meningitis use duration recommended for meningitis. If no CSF result but clinical concern about meningitis at presentation, use duration recommended for meningitis.

Staphylococcus aureus MSSA: 14 days

Staphylococcus aureus MRSA: 14 days

Streptococcus pneumoniae: 7-10 days (Meningitis 10 days)

Group A Streptococcus: 7-10 days

Group B streptococcus: 7 days (Meningitis 14 days)

Haemophilus influenzae type B: 7-10 days (Meningitis 7-10 days) 

Enterobacterales (coliforms) e.g. E. coli: 7 - 10 days (Meningitis 21 days)

Neisseria meningitidis: 5 days (Meningitis 5 days) 

If multi-drug-resistant bacteria cultured discuss with ID/Microbiology.

If concern about clinical response to treatment discuss with ID. 

IVOST to complete the total antibiotic course may be considered in bacteraemia associated with bone and joint infection, urinary tract infection, and lower respiratory tract infection. This should be discussed with ID/Microbiology.  

Hospital-acquired

If central venous access device (CVAD) check for an individualised plan for suspected CVAD line sepsis.

Please review all relevant prior culture results, discuss with ID/Microbiology if multi-drug-resistant organisms cultured.

Treatment:

  1. Age < 1 month

Discuss with ID/Microbiology

  1. Age 1 month and above

IV Piperacillin/Tazobactam + IV Gentamicin*   

If true penicillin allergy: Consult ID/Microbiology for advice.

If suspected CVAD infection add teicoplanin or vancomycin whilst awaiting blood culture results. If confirmed central line-associated bloodstream infection (CLABSI) please refer to the GGC Paediatric Line-Related Sepsis (905) guideline.

*Gentamicin should not continue beyond 3 doses, discuss with ID/Microbiology if a prolonged course of intravenous antibiotics is required. 

Duration on advice from ID/Microbiology.     

Suspected iGAS sepsis/Toxic Shock Syndrome

Treatment:

IV Cefotaxime + PO/IV Clindamycin

If true penicillin allergy: IV Vancomycin + IV Clindamycin + IV Gentamicin*

If suspected toxic shock syndrome or toxin-mediated disease requiring PICU-level care, consider addition of IVIG. Discuss with ID.

If suspected Staphylococcus aureus Toxic Shock Syndrome, discuss antibiotics with ID/Microbiology. 

Review blood cultures at 48hrs. If Group A Streptococcus is confirmed, Cefotaxime can be switched to Benzylpenicillin. 

*Gentamicin should not continue beyond 3 doses, discuss with ID/Microbiology if a prolonged course of intravenous antibiotics is required. 

Duration: 7 - 10 days
Consider stopping Clindamycin after a minimum of 5 days.

Lower Respiratory Tract Infection

Community-acquired pneumonia – not requiring hospital admission

Community-acquired pneumonia requiring hospital admission

Aspiration pneumonia

Pneumonia complicating influenza (non-severe & severe)

Empyema

Community-acquired pneumonia

1. Community-acquired pneumonia – not requiring hospital admission

If requiring hospital admission, please send a throat swab for an extended respiratory viral PCR test (includes Mycoplasma pneumoniae PCR). If productive cough, please send sputum for bacterial culture.

Treatment:

PO Amoxicillin

If true penicillin allergy: PO Azithromycin*

If Mycoplasma pneumoniae likely pathogen (consider if high community prevalence, failure of treatment with amoxicillin after 3 days, children > 5 years, mucocutaneous manifestations): PO Azithromycin*

*Azithromycin has numerous serious drug interactions, see BNFc or contact pharmacy for details.  

Duration:

  • 5 days (PO Amoxicillin)
  • 3 days (PO Azithromycin)

2. Community-acquired pneumonia requiring hospital admission

If multi-drug-resistant or toxin-producing bacteria cultured e.g. PVL-Staphylococcus aureus, discuss with ID/Microbiology.

Treatment:

PO Co-amoxiclav (IV only if not tolerating oral, or complicated pneumonia e.g. pleural effusion, lung abscess, necrosis). 

For lower respiratory tract infection in children with known conditions associated with recurrent infection (e.g. cystic Fibrosis, bronchiectasis, primary ciliary dyskinesia, primary immunodeficiencies, neurodisability) treatment should be guided by the underlying condition and previous microbiology results. Treatment should be discussed with the relevant primary team (e.g. Respiratory, Infectious Diseases/Immunology teams).

If true penicillin allergy: PO Clarithromycin. If severe disease IV Clindamycin & IV Gentamicin*

*Gentamicin should not continue beyond 3 doses, discuss with ID/Microbiology if a prolonged course of intravenous antibiotics is required. 

Duration: 5-7 days

Aspiration pneumonia

If co-morbidity (e.g. neurodisability) treatment should be guided by the underlying condition and previous microbiology results. Treatment should be discussed with the relevant primary team (e.g. Respiratory, Infectious Diseases/Immunology teams). If no previous resistant organisms cultured, treat as for community-acquired pneumonia.

Pneumonia complicating influenza (non-severe & severe)

Secondary bacterial pneumonia complicating influenza is often due to Staphylococcus aureus. If not severely unwell, treat as for community-acquired pneumonia. If unwell or signs of sepsis/toxin-mediated disease, discuss with ID/Microbiology.

Empyema

Discuss source control procedure with the Paediatric General Surgical team.

If multi-drug-resistant or toxin-producing bacteria cultured e.g. PVL-Staphylococcus aureus, discuss with ID/Microbiology.

Treatment:

IV Co-amoxiclav (+ PO/IV Clindamycin if concern about toxin-mediated disease) 

If true penicillin allergy: IV Vancomycin + IV Gentamicin* (+ PO/IV Clindamycin if concern about toxin-mediated disease).

If suspected toxic shock syndrome or toxin-mediated disease requiring PICU-level care, consider IV Cefotaxime + PO/IV Clindamycin, with addition of IVIG. Discuss with ID.

IVOST antibiotic choice should be guided by microbiology results. If Group A Streptococcus is cultured, Cefuroxime can be switched to Benzylpenicillin.

*Gentamicin should not continue beyond 3 doses, discuss with ID/Microbiology if a prolonged course of intravenous antibiotics is required. 

Duration: Total antibiotic duration 2 weeks. If needing longer due to slow response to treatment, discuss with ID. If added Clindamycin to cover for toxin-mediated disease, stop Clindamycin after 5 days.

Upper Respiratory Tract Infection

Tonsillitis (if antibiotic required)

Pertussis 

Otitis Media

Acute Sinusitis

Acute Mastoiditis

Bacterial tracheitis

Epiglottitis

Lymphadenitis

Deep neck space infection

Lemierre’s Syndrome

 

Tonsillitis (if antibiotic required)

Refer to Acute sore throat, Paediatric guideline for further information including investigations and clinical decision-making tools to support prescribing decisions and management.

If the child has stridor, respiratory distress, drooling or is systemically very unwell, consider urgent review by the ENT and PICU teams and consider diagnoses; severe croup, bacterial tracheitis or epiglottitis (see relevant section on guidance)

Treatment of tonsillitis:

PO Penicillin V (IV Benzylpenicillin if unable to tolerate oral medication)

If true penicillin allergy: PO Clarithromycin* (IV if unable to tolerate oral medication)

*Clarithromycin has numerous serious drug interactions, see BNFc for details.

Duration: 5 days unless symptoms remain at 5 days of treatment, then a further 5 days is indicated. 10 days if relapse/recurrence of tonsilitis within 2 weeks or where there are signs/symptoms of scarlet fever.

Pertussis 

Pertussis remains a notifiable disease in the UK. Suspected and confirmed cases must be notified.  Inform the NHS GGC Public Health Protection Team on 64917 Mon-Fri 9-5pm, or via the hospital switchboard and ask for the on-call team out of hours, to discuss contact tracing and antibiotic prophylaxis (prophylaxis not required for index case).

Treatment:

PO Clarithromycin*

*Clarithromycin has numerous serious drug interactions, see BNFc for details.

Duration: 7 days

Otitis Media

Children with acute otitis media should not be routinely prescribed antibiotics as most cases are viral in aetiology. Immediate antibiotics should only be given if systemically unwell or high risk of complications, or if there is no resolution or deterioration in symptoms over 3 days. Consider antibiotics (immediate or a back-up antibiotic prescription) if perforated ear drum or under 2 years of age with bilateral otitis media, in line with the NICE guideline.

Treatment:

PO Amoxicillin

If worsening symptoms on Amoxicillin taken for at least 2-3 days, recommend clinical review, and consider switching to PO Co-amoxiclav. 

If true Penicillin allergy: PO Clarithromycin*

*Clarithromycin has numerous serious drug interactions, see BNFc for details.

Duration: 

5-7 days (PO Amoxicillin)

5-7 days (PO Clarithromycin)

Acute Sinusitis

Children with acute sinusitis should not be routinely prescribed antibiotics as most cases are viral in aetiology. Immediate antibiotics should only be given if systemically unwell or high risk of complications. If symptoms for 10 days or more consider antibiotic treatment.  

If complicated by intracranial infection, refer to CNS section (cerebral abscess/subdural effusion or venous sinus thrombosis) & discuss with ID/Microbiology. 

Treatment:

PO Co-amoxiclav

If true penicillin allergy: PO Clarithromycin*

If severe: IV Cefotaxime + IV/PO Metronidazole: IVOST > PO Co-amoxiclav.

If true penicillin allergy: IV Clindamycin and IV Gentamicin**: IVOST > PO Clindamycin

*Clarithromycin has numerous serious drug interactions, see BNFc for details.

** Gentamicin should not continue beyond 3 doses, discuss with ID/Microbiology if a prolonged course of intravenous antibiotics is required. 

Duration: Minimum 5 days

Acute Mastoiditis

If complicated by intracranial infection, refer to CNS section (cerebral abscess/subdural effusion or venous sinus thrombosis) & discuss with the ID/Microbiology. 

Treatment:

IV Cefotaxime + IV/PO Metronidazole:  IVOST > PO Co-amoxiclav

If true penicillin allergy: IV Clindamycin and IV Gentamicin*: IVOST > PO Clindamycin

* Gentamicin should not continue beyond 3 doses, discuss with ID/Microbiology if a prolonged course of intravenous antibiotics is required. 

Duration: 14 days total 

Bacterial tracheitis

Treatment:

IV Cefuroxime + IV/PO Clindamycin: IVOST > PO Co-amoxiclav  

If true penicillin allergy: IV/PO Clindamycin + IV Gentamicin*: IVOST > PO Clindamycin

*Gentamicin should not continue beyond 3 doses, discuss with ID/Microbiology if a prolonged course of intravenous antibiotics is required. 

Duration: Minimum 5 days and review.

Epiglottitis

Treatment:

IV Cefotaxime: IVOST > PO Co-amoxiclav

If true penicillin allergy: IV/PO Clindamycin + IV Gentamicin*: IVOST> PO Clindamycin

*Gentamicin should not continue beyond 3 doses, discuss with ID/Microbiology if a prolonged course of intravenous antibiotics is required. 

Duration: Minimum 5 days and review.

Lymphadenitis

Treatment:

PO Co-amoxiclav. If severe disease IV Co-amoxiclav.

If true penicillin allergy: PO Clindamycin. If severe disease discuss with ID/Microbiology. Consider addition of IV Gentamicin*

*Gentamicin should not continue beyond 3 doses, discuss with ID/Microbiology if a prolonged course of intravenous antibiotics is required. 

Duration: 7 days

Deep neck space infection

Treatment:

Consider drainage to attain source control.

IV Cefotaxime + IV/PO Metronidazole:  IVOST > PO Co-amoxiclav.

If true penicillin allergy: IV/PO Clindamycin + IV Gentamicin*:  IVOST > PO Clindamycin.

* Gentamicin should not continue beyond 3 doses, discuss with ID/Microbiology if a prolonged course of intravenous antibiotics is required. 

Duration: 10-14 days

Lemierre’s Syndrome

If suspected discuss with the ID team.

Treatment:

IV Cefotaxime + IV/PO Metronidazole:  IVOST> PO Co-amoxiclav

If true penicillin allergy: IV/PO Clindamycin + IV Gentamicin*:  IVOST> PO Clindamycin

* Gentamicin should not continue beyond 3 doses, discuss with ID/Microbiology if a prolonged course of intravenous antibiotics is required. 

Duration: Minimum 3 weeks, total duration dependent on clinical response, discuss with ID.

Orbital Infections

Pre-septal Cellulitis

Orbital Cellulitis

Pre-septal Cellulitis

For further information refer to Preseptal cellulitis in children (1075)

Treatment:

PO Co-amoxiclav

If true penicillin allergy: PO Clindamycin

Duration: 7 days

Orbital Cellulitis

For further information on assessment and management refer to Orbital and periorbital cellulitis in children (225).

If complicated by intracranial infection, refer to CNS section (cerebral abscess/subdural effusion or venous sinus thrombosis) & discuss with ID/Microbiology.

Treatment:

IV Cefotaxime + IV/PO Clindamycin: IVOST > Co-amoxiclav.

If no improvement after 48 hours, add IV/PO Metronidazole whilst awaiting the results of intra-cranial imaging.   

If true penicillin allergy: IV/PO Clindamycin + IV Gentamicin*: IVOST > PO Clindamycin

* Gentamicin should not continue beyond 3 doses, discuss with ID/Microbiology if a prolonged course of intravenous antibiotics is required. 

Duration: 10-14 days  

Gastro-Intestinal Infections

Gastroenteritis

Appendicitis

Intra-abdominal infection

Intra-abdominal abscess

Cholangitis

Helicobacter pylori Infection

Clostridium Difficile Infection

Gastroenteritis

No antibiotics usually required.

Appendicitis

Treatment:

IV Cefotaxime + IV/PO Metronidazole (PO when tolerating oral medications)

If true penicillin allergy: IV Ciprofloxacin* + IV/PO Metronidazole (PO Ciprofloxacin + PO Metronidazole when tolerating oral medications). 

If concerns about sepsis add IV Gentamicin**

IVOST antibiotic choice should be guided by microbiology results (including intra-operative sample cultures).

*Please see MHRA alert on fluoroquinolone antibiotics.

**Gentamicin should not continue beyond 3 doses, discuss with ID/Microbiology if a prolonged course of intravenous antibiotics is required. 

Duration:

Simple: 24 hours

Complex (perforation, necrosis): 5 days total

Intra-abdominal infection

Treatment:

IV Cefotaxime + IV/PO Metronidazole  (PO when tolerating oral medications)

If true penicillin allergy: IV Ciprofloxacin* + IV Metronidazole (PO Ciprofloxacin + PO Metronidazole when tolerating oral medications).  

If concerns about sepsis add IV Gentamicin**

IVOST antibiotic choice should be guided by microbiology results (e.g. intra-operative, ascitic fluid cultures).

*Please see MHRA alert on fluoroquinolone antibiotics.

**Gentamicin should not continue beyond 3 doses, discuss with ID/Microbiology if a prolonged course of intravenous antibiotics is required. 

Duration: Minimum total 5 – 7 days

Intra-abdominal abscess

Source control most effective. If source control not possible, then discuss with ID/Microbiology.

Cholangitis

Refer to Cholangitis pathway for further information.

Helicobacter pylori Infection

Refer to Helicobacter pylori infection guidelines for further information.

Clostridium Difficile Infection

Refer to CDI guidelines for further information.

Urinary Tract

See Urinary Tract Infection, Acute Management in Children guideline for definitions of urinary tract infection (UTI), including symptoms suggestive of upper and lower UTI.

If a child is known to the renal service or has had previous UTIs then please check previous urine culture results as this may influence empiric antibiotic prescribing decisions.

Upper Tract Infection/Pyelonephritis

Lower Tract Infection

Upper Tract Infection/Pyelonephritis

If suspected sepsis, unable to tolerate oral antibiotics or patient below 3 months of age:

Treatment:

IV Cefotaxime* (consider one-off dose of Gentamicin if suspected sepsis or unwell neonate)

If true penicillin allergy: Use Gentamicin** initially and discuss with ID/Microbiology.

*Consider switching IV cefotaxime to IV ceftriaxone when stable and clinical improvement. See BNFc dosing recommendation. See cautions/contraindications for ceftriaxone in neonates in the BNFc.

**Gentamicin should not continue beyond 3 doses, discuss with ID/Microbiology if a prolonged course of intravenous antibiotics is required. 

Duration: 7-10 days (min 48 hours IV then review for IVOST) 

If no suspected sepsis, able to tolerate PO antibiotics, in patients 3 months of age and above:

Treatment:

PO Cefalexin

If true penicillin allergy: PO Ciprofloxacin* 

*Please see MHRA alert on fluoroquinolone antibiotics

Duration: 7 days

Lower Tract Infection

Treatment:

PO Cefalexin

If true penicillin allergy and over 3 months of age: PO Nitrofurantoin

If true penicillin allergy and under 3 months of age: Discuss with ID/Microbiology

Duration: 3 days

Bone/Joint Infection

Septic arthritis / Osteomyelitis

If infection is associated with metalwork, please discuss antibiotic choice and duration of treatment with ID/Microbiology.

Treatment

1. Age 3 months and below:

IV Cefotaxime: IVOST > PO Co-amoxiclav

If true penicillin allergy: Discuss with ID/Microbiology

2. Age 3 months to up to 5 years
IV Cefuroxime: IVOST > Co-amoxiclav

If true penicillin allergy: IV Clindamycin: IVOST> PO Clindamycin. If suspected K. kingae infection*, consider Co-trimoxazole**. Discuss with ID/Microbiology.

3. Age 5 years and above
IV Flucloxacillin: IVOST > PO Flucloxacillin or Co-amoxiclav liquid if Flucloxacillin not tolerated

If true penicillin allergy: IV Clindamycin: IVOST > PO Clindamycin.

4. If Sickle Cell Disease or no Haemophilus Influenza B vaccine
IV Cefotaxime: IVOST > PO Co-amoxiclav

If true penicillin allergy: IV Clindamycin: IVOST > PO Clindamycin.

Modify treatment according to culture results & clinical response. Discuss with ID/microbiology.

*Consider K. Kingae infection < 5yrs, CRP < 40mg/L, involvement knee or shoulder joint.

**Co-trimoxazole is not licenced for use in children <6 weeks of age. Co-trimoxazole can cause blood disorders and electrolyte disturbance. See BNFc for cautions and contraindications for use. Measure baseline bloods (UE, FBC).  If blood test results are abnormal, discuss treatment recommendations and monitoring with ID/Microbiology.

If blood tests are normal and treatment duration of oral co-trimoxazole extends beyond 2 weeks, patients should have repeat blood test monitoring (UE, FBC) at 2 weeks. This can be at a follow-up orthopaedic out-patient appointment or arranged on ward 1C. If unsure, please discuss monitoring requirements and results with ID/Microbiology. Counsel patients and parents/carers about the risk of drug allergy, i.e. that if patients develop a rash whilst taking co-trimoxazole they should stop taking it immediately and seek medical advice.  

Duration: 2-3 weeks in septic arthritis, 3-4 weeks in osteomyelitis. For complex disease* or infants under 3 months of age: 6 weeks total (2 weeks IV then PO) or longer if not resolved.

*Complex disease: Multifocal, significant bone loss, unusual or resistant pathogen, immunosuppressed patient, sepsis or shocked, infection associated with metalwork.

Review all IV antibiotics at 48hrs. IVOST should be considered for osteomyelitis/septic arthritis: when patient is afebrile, pain free for >24 hours and when CRP is <20mg/l or has reduced by 2/3 of its highest value. Ensure no signs of complications (e.g. metastatic foci inc. endocarditis, pneumonia or DVT), no growth of virulent pathogens (e.g. PVL-Staphylococcus aureus), and negative blood cultures before IVOST.

Skin/Soft Tissue

Abscess

Cellulitis

Necrotising Fasciitis

Infected Human/Animal bite

Abscess

Refer to the General Surgical Team – may need incision and drainage.

Cellulitis

If severe sepsis refer to the section on Sepsis and discuss with ID/Microbiology.  

If severe cellulitis or pain out of proportion with clinical findings, consider necrotising fasciitis. See the section on Necrotising Fasciitis.

In patients with previous culture of MRSA on skin/soft tissue samples please be guided by previous microbiology antibiotic sensitivity results. Isolates may be sensitive to clindamycin or co-trimoxazole. If no available oral antibiotic options discuss antibiotic management with ID/Microbiology.

Treatment:

IV Flucloxacillin: IVOST > PO Flucloxacillin 

If true penicillin allergy: IV Clarithromycin* or IV Clindamycin: IVOST > PO Clarithromycin or PO Clindamycin 

Modify therapy according to culture results and the clinical response.

*Clarithromycin has numerous serious drug interactions, see BNFc for more details. 

Duration: 5-7 days

Necrotising Fasciitis

Discuss the patient immediately with the paediatric surgical and plastic surgery teams; necrotising fasciitis requires rapid debridement of all infected tissues in combination with empirical antibiotic therapy.

A multidisciplinary approach (General Surgery, Plastic Surgery, ID/Microbiology, and PICU) is required.

Whilst the patient is waiting for surgery, monitor them for signs of sepsis or toxin-mediated disease, as well as local signs and symptoms of extension of the area of necrotising fasciitis.

Treatment:

IV Cefotaxime + IV/PO Clindamycin + IV/PO Metronidazole + IV Gentamicin*

If true penicillin allergy or if MRSA suspected REPLACE Cefotaxime with Vancomycin

In perineal infection consider Piperacillin-tazobactam (Tazocin) in place of cefotaxime if no penicillin allergy, especially if gentamicin is contra-indicated. Discuss with ID/Microbiology if penicillin allergy.

If known colonisation with multi-drug-resistant organisms discuss with ID/Microbiology.

Rationalise antibiotics in line with culture results and clinical progress.

*Gentamicin should not continue beyond 3 doses, discuss with ID/Microbiology if a prolonged course of intravenous antibiotics is required. 

Duration: 10-14 days total. Consider IVOST when clinical improvement, no spreading infection, afebrile for over 24hrs.

Infected Human/Animal bite

See NICE guidance for risk stratification and treatment recommendations for bites.

  • Seek specialist advice from ID for bites from a wild or exotic animal or farm animals (including birds and non-traditional pets).
  • Refer to Management of possible rabies exposure in children and young people (1192) in patients who have been bitten by an animal outside of the UK, or by a bat within the UK.
  • Assess the risk of tetanus, rabies or a bloodborne viral infection and take appropriate action.

For antibiotic prophylaxis for uninfected bites refer to the NICE guidance.

The following recommendations are for infected bites:

  • If there is discharge from the wound, take a swab for microbiological testing to guide treatment. Review antibiotic choice based on swab results.
  • Manage the wound with irrigation and debridement as necessary.

Treatment of an infected bite

Age below 1 month: Seek advice from ID/Microbiology.

Age 1 month and over: PO Co-amoxiclav. If patient is unable to take oral antibiotics or if severely unwell IV Co-amoxiclav may be given.  

If true penicillin allergy:

Age 6 weeks to 11 years: PO Co-trimoxazole. If patient is below 6 weeks of age, seek advice from an ID/Microbiology, as Co-trimoxazole is not licenced for this age group.

Age 12 to 17 years: PO Doxycycline + PO Metronidazole.  

Treatment of deep bites/severe infection/unable to tolerate oral antibiotics

Discuss all patients with suspected sepsis with ID/Microbiology

IV Co-amoxiclav

Penicillin Allergy (low risk; no anaphylaxis after penicillin):

IV Cefuroxime + IV/PO Metronidazole (Replace IV Cefuroxime with IV Cefotaxime if suspected sepsis)

Penicillin Allergy (High risk; anaphylaxis or severe systemic reaction after penicillin):

IV Vancomycin + IV/PO Ciprofloxacin* + IV/PO Metronidazole

*Please see MHRA alert on fluoroquinolone antibiotics

Duration:

A 5-day course is appropriate for treating most human or animal bites, but course length can be increased to 7 days (with review) based on clinical assessment of the wound, for example, if there is significant tissue destruction or it has penetrated bone, joint, tendon or vascular structures. If the wound is infected — review at 24 and 48 hours to ensure the infection is responding to treatment. If patient is discharged, advice to attend urgently for review if the infection worsens or if they feel increasingly unwell.

Editorial Information

Last reviewed: 29/07/2026

Next review date: 31/07/2029

Author(s): Shahad Abbas, Paediatric Antimicrobial Pharmacist, Katherine Longbottom, Consultant in Paediatric Infectious Disease, Louisa Pollock, Consultant in Paediatric Infectious Disease.

Version: 1

Author email(s): shahad.abbas@nhs.scot.

Approved By: NHSGGC Antimicrobial Utilisation Committee

Document Id: 1288