Empirical antibiotic guidelines for primary care

Cellulitis/Impetigo

If mild/moderate infection, cefalexin 25mg/kg 8 hourly (max 1g per dose) or co-amoxiclav. Use clarithromycin if confirmed penicillin allergy.

Duration of antibiotic course 5 days.

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.

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Conjunctivitis

Usually no treatment required; viral cause most likely (adenovirus, enterovirus, occasionally herpes simplex). Consider ophthalmia neonatorum in a neonate; this does not refer to a simple "sticky eye" in a neonate and requires urgent review in hospital

Consider chloramphenicol eye drops and chloramphenicol ointment 1%. Continue until 2 days after symptoms resolved.

Lymphadenitis

If lymphadenopathy is bilateral, non-erythematous, non-tender, with node size less than 3 cm, and child systemically well, consider no treatment, watchful waiting approach. Low threshold for treatment if child immunocompromised.

If mild, cefalexin 25mg/kg 8 hourly (max 1g per dose) or co-amoxiclav

Duration of antibiotic course 7 days

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Otitis Externa

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

First line: acetic acid

Second line: neomycin with corticosteroid

If cellulitis and disease extending outside ear canal, start oral Abs based on sensitivities. Empirical treatment with cefalexin 25mg/kg 8 hourly (max 1g per dose) or co-amoxiclav.

Use azithromycin for 3 days if confirmed penicillin allergy.

Otitis Media

Acute otitis media resolves in 60% by 24 hours without Abs. Abs only marginally reduces pain at 2 days (NNT 15) and does not prevent deafness. Need to treat 4800 with antibiotics to avoid 1 case of mastoiditis.

If ear discharge but systemically well and apyrexial, treat with topical antibiotics (sofradex or neomycin) for 10 days.

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 for 4 days or more
  • Purulent discharge from ear canal (not due to otitis externa)
  • Systemically unwell
  • Under 6 months of age with presumed acute OM.

In child 6 months - 2 years old:-

  • bilateral OM
  • unilateral OM and symptom score of >8 (0=no symptoms, 1=a little, 2-a lot) for the following criteria:-
  • fever (>39 degrees = score of 2).
  • tugging ears
  • crying more
  • irritability
  • difficulty sleeping
  • less playful
  • eating less

Treat with amoxicillin 40mg/kg 12 hourly (max 1g per dose) 12 hourly for 5 days.

If failed treatment with amoxicillin, co-amoxiclav for 5 days

Use azithromycin for 3 days if confirmed penicillin allergy

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Pneumonia

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.

Amoxicillin 40mg/kg bd (max 1g per dose) 12 hourly (or co amoxiclav if no response to amoxicillin). Duration of antibiotic course 5 days. Use azithromycin for 3 days if confirmed penicillin allergy.

If severe or complicated pneumonia (O² sats<85%, haemodynamic instability/septicaemia, immunocompromised, chronic lung disease, congenital hear disease, empyema, necrotising pneumonia), for urgent review in hospital - call pediatrician.

Treatment for atypical infections should only be considered in sever infection if no response to first line empirical therapy - use azithromycin.

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Rhinosinusitis

Generally Abs are not required as 80% resolve within 14 days without Tx (NNT 15). Offer adequate analgesia.

Treat if worsening upper respiratory tract symptoms (fever, daytime cough or nasal discharge) following resolution of viral UTI, severe symptoms (fever >39 degrees, purulent nasal discharge) or persistent symptoms (nasal discharge or daytime cough >10 days).

Amoxicillin 40mg/kg bd (max 1g per dose) 12 hourly if no previous treatment in preceding 4 weeks. If treatment with amoxicillin in preceding 4 weeks, co-amoxiclav. Duration of treatment 7 days after improvement in symptoms (usually 10-14 days)

Use azithromycin for 3 days if confirmed penicillin allergy.

Tonsillitis

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 (Cochrane review 2013). Need to treat >4000 children with antibiotics to prevent one case of quinsy.

Most children with tonsillitis do not require a throat swab.

Base decision to treat on FeverPAIN 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 = 18% streptococci: use NO antibiotics
  • score 2-3: 34-40% streptococci, use back up/delayed antibiotic
  • score ≤4: 62-65% streptococci, use immediate Ab.
  • Based on Little et al, BMJ 2013

Score validated in children 3 years and over - younger children are less likelyto have a bacterial aetiology and are less likely to develop complications.

For children unable to swallow tablets; amoxicillin 40mg/kg bd (max 1g per dose) for 7 days (2012 Cochrane review). The use of amoxicillin does not significantly increase the risk of rash in acute EBV.

For children able to swallow tablets; if age 6-12 years, penicillin V 500mg bd; if age >12 years, penicillin V 1g bd for 7 days.

Use azithromycin for 5 days if confirmed penicillin allergy.

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Urinary Tract Infection

<3 months of age: treat as pyelonephritis (needs review on hospital - call pediatrician).

>3 months of age with lower UTI/cystitis: trimethoprim (or nitrofurantoin if able to tolerate tablets).

If previous treatment with trimethoprim in preceding 4 weeks, use co-amoxiclav.

Ciprofloxacin if confirmed penicillin allergy and unable to swallow nitrofurantoin tablets.

Duration of antibiotic course - 3 days.

>3 months of age with upper UTI/pyelonephritis (all children with a febrile UTI should be considered to have pyelonephritis):

Treat empirically with co-amoxiclav unless able to tolerate oral Abs or systemically unwell (suggestive of bacteraemia).

Ciprofloxacin if confirmed penicillin allergy.

If unable to tolerate oral Abs or systemically unwell (suggestive of bacteraemia), requires review in hospital for consideration of IV antibiotics - call pediatrician).

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