www.drhelenallergy.co.uk
When to treat
Assess the severity of the bite:
Refer immediately to hospital if there are signs of a serious illness or a penetrating wound involving bones, joints, tendons or vascular structures.
Refer to A&E for further assessment and management if either:
Consider referral or seeking specialist advice if the person:
Antibiotics are not generally needed if the wound is more than 2 days old and there is no sign of local or systemic infection.
Do not offer antibiotics if the bite has not broken the skin.1,2
Offer antibiotics if the bite is infected (e.g. increased pain, inflammation, fever, discharge or unpleasant smell).1,2 Take a swab for micro testing if there is discharge from the wound.
Establish what has caused the bite and select appropriate action below.
Reassess if:
PROPHYLAXIS:
Wild animals, exotic animals (including bird and non-traditional pets), bats, domestic animals you are unfamiliar with including farm animals:
Seek specialist advice from microbiologist or consultant in infectious diseases.1
Cat bite:
Offer antibiotics If the bite has broken skin and drawn blood1,2
Consider antibiotics if the bite has broken skin but not drawn blood if the wound could be deep.1,2
Do NOT offer antibiotics if the bite has broken skin but not drawn blood.1,2
Consider tetanus immunoglobulin if animal bite in children with incomplete tetanus immunisation status and administer vaccine if not received within past 10 years.
Consider rabies risk if animal from abroad.
Dog (or other traditional pet) bite:
Offer antibiotics if the bite has broken skin AND drawn blood IF it has caused considerable, deep tissue damage or is visibly contaminated (for example, with dirt or a tooth).1,2
Consider antibiotics if the bite has broken skin and drawn blood if the bite:1,2
Human:
Thorough irrigation of the wound is important.
Offer antibiotics if the bite has broken skin and drawn blood.1,2
Consider antibiotics if the bite has broken the skin but not drawn blood and if the bite:
Assess risk of tetanus, HIV, Hepatitis B & C and viral blood borne infection: Seek immediate advice from a consultant in microbiology or infectious diseases or PHE consultant in accordance with local processes / risk assessments. Consider if tetanus prophylaxis is required based on immunisation status and risk status of the wound.
When to investigate1,2
If there is a discharge (purulent or non-purulent), take a swab for microbiological testing to guide treatment. State on the form that the swab is from an infected human bite or an infected animal bite.
TREATMENT:
For children aged 5 years and over, consider prescribing capsules and signposting to pill swallowing resources; if the child is unable to swallow the tablets/capsules, see the advice on opening capsules / crushing tablets from Specialist Pharmacy Service (SPS) about using solid oral dosage form antibiotics in children.
First line prophylaxis or treatment1,3
Co-amoxiclav (Total duration should be for 3 days (prophylaxis) or 5 days (treatment))
1-11 months: Co-amoxiclav 125/31/5ml liquid 0.25 mL/kg po TDS 1-5 years: Co-amoxiclav 125/31/5ml liquid 5 mL po TDS 6-11 years: Co-amoxiclav 250/62/5ml liquid 5 mL po TDS 12-17 years: Co-amoxiclav tablets (500/125 mg) 1 tablet po TDS or co-amoxiclav (250/62/5ml) liquid 10 mL po TDS
If allergic to penicillin1,3 (NOTE: incorrectly labelling a child with a penicillin allergy has a lifelong impact on mortality and morbidity (click here for information on correctly applying penicillin labels in children) and/or watch Dr Helen Evans-Howells GP WER Allergy and Simon Williams from Anaphylaxis UK discuss getting the diagnosis correct with drug allergies):
Aged under 12 years old:
Co-trimoxazole po for 3 days for prophylaxis or 5 days for treatment
Child 6 weeks-5 months: 120mg po BD (off-label)
Child 6 months-5 years: 240mg po BD (off-label)
Child 6-11 years: 480mg po BD (off-label)
Review child at 24 and 48 hours, as not all pathogens are covered.
Aged 12 years and over:
Doxycycline Day 1: 200mg po STAT then Day 2 onwards 100mg or 200mg po OD.3 Total duration should be for 3 days for prophylaxis or 5-7 days for treatment. PLUS Metronidazole 400mg po TDS for 3 days for prophylaxis or 5-7 days for treatment.
General advice
Advise patient to seek medical help if an infection:
References
Click here for a link to South Central Antimicrobial Network (SCAN) Guidelines for Antibiotic Prescribing in the Community.
Click here for tips for antibiotic prescribing in children and the evidence base supporting them
Last updated
March 2022
Oral candidiasis is rare in immunocompetent people. Consider undiagnosed risk factors including HIV infection.1
Stop unnecessary antibiotics and advise parent/carer to sterilise dummy.3
Treatment choices:
Localised or mild infection - first line
Miconazole oral gel 20mg/g1
Continue for 7 days after lesions have healed or symptoms have cleared.2
For neonate and child under 2 years old, smear around the inside of the mouth after feeds.2
Child over 2 years: dental prostheses and orthodontic appliances should be removed at night and brushed with gel.2
Neonate: 1 mL by mouth BD to QDS after feeds2
1-23 months: 1.25 mL by mouth QDS after feeds2
2-17 years: 2.5 mL by mouth QDS2 after meals, apply near oral lesions before swallowing
Localised or mild infection - second line (if miconazole not tolerated)
Nystatin oral suspension 100,000 units/ml1
Continue treatment for a further 2 days after lesions have healed2
Apply 1 mL by mouth QDS after feeds or meals2
Extensive or severe infection1
Fluconazole1 for 7-14 days (may be extended in severely immunocompromised patients)*
Child 1 month-11 years:2
Day 1: 3-6mg/kg (max dose 100mg) then from day 2 onwards: 3mg/kg daily (max dose 100 mg)
Child 12-17 years:2 50mg po OD (can be increased to 100mg po OD for unusually difficult infections2 or immunocompromised1)
* - Check drug interactions and contraindications when prescribing oral terbinafine using BNFc or Summary of Product Characteristics.
Cellulitis presents with an acute onset of red, painful, hot, swollen, and tender skin, with possible blister or bullae formation. The leg is the most commonly affected site, presentation is usually unilateral. Often (but not always) associated with a break in the skin (portal entry). For facial cellulitis, see below.
If patient afebrile and tolerating oral antibiotics, can be managed in primary care. Caution with immunocompromised patients. NOTE: oral flucloxacillin (suspension) is extremely unpalatable and is poorly tolerated by the majority of children.
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.
Most children with cellulitis or impetigo do not require skin swabs sent, unless portal of entry, extensive infection, not responding to treatment or recurrent episodes. If recurrent or severe staph aureus infection, consider requesting PVL toxin testing.
First line
Cefalexin2 for 5-7 days
12.5mg/kg po BD (max 1g per dose) or
1-11 months: 125mg po BD
1-4 years: 125mg po TDS
5-11 years: 250mg po TDS
12 years and over: 500mg po BD-TDS
OR
Flucloxacillin for 5-7 days1,3 (Note: Oral flucloxacillin (suspension) is extremely unpalatable and is poorly tolerated by the majority of children)
1-23 months: 62.5-125mg po QDS
2-9 years: 125-250mg po QDS
10-17 years: 250-500mg po QDS
If allergic to penicillin (NOTE: incorrectly labelling a child with a penicillin allergy has a lifelong impact on mortality and morbidity (click here for information on correctly applying penicillin labels in children) and/or watch Dr Helen Evans-Howells GP WER Allergy and Simon Williams from Anaphylaxis UK discuss getting the diagnosis correct with drug allergies):
Clarithromycin for 7 days3
Under 8 kg: 7.5mg/kg po BD
8 to 11 kg: 62.5mg po BD
12 to 19 kg: 125mg po BD
20 to 29 kg: 187.5mg po BD
30 to 40 kg: 250mg po BD 12 to 17 years: 500mg po BD
Erythromycin (if pregnant)3
8-17 years: 1g po BD2
FACIAL CELLULITIS:
If facial cellulitis
If severe facial cellulitis, refer to secondary care.
Co-amoxiclav1,2,3 for 7 days3
1-11 months: co-amoxiclav 125/31/5ml liquid 0.25 mL/kg po TDS
1-5 years: co-amoxiclav 125/31/5ml liquid 5 mL po TDS (dose doubled in severe infection)
6-11 years: co-amoxiclav 250/62/5ml liquid 5 mL po TDS (dose doubled in severe infection)
12-17 years co-amoxiclav tablets (500/125 mg) 1 tablet po TDS or co-amoxiclav 250/62/5ml liquid 10 mL po TDS
If facial cellulitis and allergic to penicillin (NOTE: incorrectly labelling a child with a penicillin allergy has a lifelong impact on mortality and morbidity (click here for information on correctly applying penicillin labels in children) and/or watch Dr Helen Evans-Howells GP WER Allergy and Simon Williams from Anaphylaxis UK discuss getting the diagnosis correct with drug allergies):
PLUS (if anaerobes suspected)
Metronidazole for 7 days3
1 month: 7.5mg/kg po BD
2 months-11 years: 7.5mg/kg (max 400mg per dose) po TDS
12-17 years: 400mg po TDS
Cautions
Aim to use an antibiotic that minimises dosing frequency and is palatable (if suspension prescribed) to optimise adherence. Oral flucloxacillin (suspension) is extremely unpalatable and is poorly tolerated by the majority of children.
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.
Bacterial conjunctivitis: usually unilateral and also self-limiting. It is characterised by red eye with mucopurulent, not watery discharge. 65% and 74% resolve on placebo by days 5 and 7 respectively.
Treat only if severe as most cases are viral or self-limiting.
Safety netting
Provide written and verbal advice
Treatment choices for bacterial conjunctivitis
Bathe / clean eyelids with cotton wool dipped in sterile saline or boiled (cooled) water (to remove crusting) TDS or QDS. Wipe away from the bridge of the nose to the side.
Advise patient / carer that good hand hygiene is required.
Second line3
Consider Chloramphenicol 0.5% eye drops (apply 1 drop every 2 hours then reduce frequency as infection is controlled, frequency dependent on the severity of the infection. For less severe infection 3-4 times daily is generally sufficient)
PLUS Chloramphenicol eye ointment 1% (Apply at night)
Continue until 2 days after symptoms resolved.
There was a MHRA drug safety alert regarding Chloramphenicol eye drops containing borax or boric acid buffers: use in children younger than 2 years in July 2021. This contains counselling points for parents / carers of children under 2 years old. Please use this information to support discussions if prescribing chloramphenicol eye drops for children under 2 years old.
Advise patient about self-management:
Arrange follow up to confirm diagnosis and ensure that symptoms have resolved.
Consider referral to ophthalmology if symptoms persist for more than 7 to 10 days after initiating treatment.
DERMATOPHYTE INFECTION - SKIN / SCALP
The diagnosis of suspected fungal infection of the body and groin should be made on the basis of clinical features.1
When to investigate
Send skin scrapings if intractable infection or infection of the scalp.2,3
Wash the affected skin daily and dry thoroughly afterwards, wash clothes and bed linen frequently, don’t share towels and wash them frequently, wear loose-fitting clothes made of cotton.1
Treatment choices
Licensing of topical and oral azoles varies. Check with local formularies before prescribing.
Topical products
Body
Terbinafine2 1% cream apply thinly OD-BD for 1-2 weeks, review treatment after 2 weeks4
Or
Imidiazole2 cream for 4-6 weeks2. See local formulary for product choice.
Candida infection (suspected and confirmed)
Imidazole cream2 continued for 1-2 weeks after healing1
Foot (athelete’s foot)
Topical undecenoates e.g. Mycota® which should be applied BD. Continue use for 7 days after lesions have healed.4
Scalp
Oral terbinafine (dosing as below). If not responding after 6 weeks, review. Refer if no regeneration of hair to a specialist.
Oral terbinafine (dosing as below) for 4 weeks4
Groin
Oral terbinafine (dosing as below) for 2-4 weeks4
Foot
Oral terbinafine (dosing as below) for 2-6 weeks4
DERMATOPHYTE INFECTIONS (NAILS)
Take nail clippings. Start therapy only if infection is confirmed.1
Oral terbinafine.
6 week treatment course for fingernails, 12 weeks for toenails. If not responding after 6-12 weeks, review and seek dermatology specialist advice.
Oral terbinafine dosing
If infection is intractable and infection has been CONFIRMED:
Terbinafine4 dosing for children 1-17 years:
Weight 10-19 kg: 62.5mg po OD
Weight 20-39 kg: 125mg po OD
Weight 40 kg and above: 250mg po OD
If prescribing oral terbinafine: monitor LFTs before treatment and then periodically after 4-6 weeks of treatment. Discontinue if abnormalities in liver function tests.4
Check drug interactions and contraindications when prescribing oral terbinafine using BNFc or Summary of Product Characteristics.
1. NICE CKS. Fungal skin infection – body and groin. Last revised 05/18. Available via LINK accessed 11/21
2. NICE & PHE. Summary of antimicrobial prescribing guidance – managing common infections LINK accessed 11/21
3. NICE CKS. Fungal skin infection – scalp. Last revised 04/18. Available via LINK accessed 11/21
4. BNFc accessed LINK 11/21
5. NICE CKS. Candida – skin. Last revised 05/17. Available via LINK accessed 11/21
6. NICE CKS. Fungal skin infection – foot. Last revised 04/18. Available via LINK. accessed 11/21
When to treat1
If a child has been in close contact with a case of scarlet fever or strep throat, they do not need to be treated with prophylactic antibiotics unless they are showing signs of scarlet fever or strep throat (severe tonsillitis with fever in the absence of a runny nose). Only in exceptional circumstances will the local public health team recommend for an entire school class to be treated with antibiotics.
Scarlet fever:
General advice1
Testing
Scarlet fever is a clinical diagnosis. Routine sending of a throat swab is not required, unless treatment failure and reattendance
Notify the local health protection team promptly within 3 days by completing a notification form if a diagnosis of scarlet fever is suspected.
Amoxicillin for 5 days if Gp A strep tonsillitis suspected and 10 days if clinical diagnosis of scarlet fever)
By age:
1 month-11 months: 125mg po TDS3
1 years-4 years: 250mg po TDS3
5 years and over: 500mg po TDS3
Where TDS dosing is impractical: 40mg/kg po BD4 (max 1g per dose) could be considered. This is off-label8,9,10
Phenoxymethylpenicillin (Penicillin V)1 for 5 days (or 10 days if clinical diagnosis of scarlet fever) - Note: The unpleasant taste and palatability of Phenoxymethylpenicillin (Penicillin V) suspension can affect adherence to antibiotics, which may result in treatment failure.
1 month-11 months: 125 mg po BD1
1 year-5 years: 250 mg po BD1
6 years-11 years: 500 mg po BD1
12 years-17 years: 1g po BD1
Clarithromycin1 for 5 days if Gp A strep tonsillitis suspected and 10 days if clinical diagnosis of scarlet fever
Weight-based for 1 month to 11 years:
8-11 kg: 62.5mg po BD
12-19 kg: 125mg po BD
20-29 kg: 187.5mg po BD
30-40 kg: 250mg po BD
12 - 17 years: 500mg po BD
Erythromycin1 (if pregnant) for 5 days if Gp A strep tonsillitis suspected and 10 days if clinical diagnosis of scarlet fever
8 years-17 years: 500mg- 1g po BD
Aim to use an antibiotic that minimises dosing frequency and is palatable (if suspension prescribed) to optimise adherence.
Phenoxymethylpenicillin (penicillin V) and flucloxacillin suspensions given QDS are not well tolerated by children.
Feb 2023
Most children with impetigo do not require skin swabs sent, unless portal of entry, extensive infection, not responding to treatment or recurrent episodes.
If recurrent or severe Staph. aureus infection, consider requesting PVL testing.
Localised non-bullous impetigo
Use a topical antiseptic, such as Hydrogen peroxide 1% cream (Crystacide®)1, applied BD-TDS2 for 5-7 days1,2
Use topical antibiotics (Fusidic acid 2% cream or Mupirocin 2% ointment)1 TDS for 5-7 days1,2
Widespread non-bullous or bullous impetigo with systemic symptoms
Treat with oral antibiotics (oral flucloxacillin (suspension) is extremely unpalatable and is poorly tolerated by the majority of children).
Most insect bites or stings will not need antibiotics.1
Consider prescribing antihistamine in patients over 1 year old to help relieve itching.1,2
Do NOT offer antibiotics if there are no signs or symptoms of infections.1,2
If signs of symptoms of infection see Cellulitis section
1. NICE. Insect bites and stings: antimicrobial prescribing. [NG182]. September 2020. Accessed at LINK 11/21
If cervical lymphadenopathy is bilateral, non-erythematous, non- tender, with node size less than 3cm, and child systemically well, consider a no treatment, watchful waiting approach.
Low threshold for treatment if child immunocompromised.
If child is systemically unwell with cervical lymphadenitis symptoms, this is suggestive of acute bacterial cause - treat with antibiotics.3
RED FLAGS requiring an URGENT review and ENT input:
Provide verbal and written advice
If mild/moderate infection
Cefalexin3 for 7 days
1-11 months: 125mg po BD1
1-4 years: 125mg po TDS1
5-11 years: 250mg po TDS1
12 years and over: 500mg po BD-TDS1
Clarithromycin1,3 for 7 days
1. BNFc accessed at LINK 11/21
2. Malhotra-Kumar S, Lammens C, Coenen S, Van Herck K, Goossens H. Effect of azithromycin and clarithromycin therapy on pharyngeal carriage of macrolide-resistant streptococci in healthy volunteers: a randomised, double-blind, placebo-controlled study. Lancet. 2007 Feb 10;369(9560):482-90 LINK
3. Antimicrobial paediatric prescribing summary for hospitals; UK PAS group LINK last updated 9/21, accessed 12/21
Cure rates similar at 7 days for topical acetic acid or topical Ab +- steroid.
If cellulitis and disease extending outside ear canal, start oral antibiotics based on sensitivities and arrange urgent ENT review.
Ear spray Acetic acid 2% (EarCalm spray®) ONE spray TDS for 7 days1 (unlicensed use)
Analgesia for pain relief and apply localised heat (such as a warm flannel)1,3
Second line
Aminoglycoside + steroid (contraindicated in perforated tympanic membrane)3:
Neomycin + steroid ear drops / spray:
Drops: Betnesol-N® , Otosporin® THREE drops TDS for 7 - 14 days (or equivalent generic product). See BNFc for duration for each product.
Spray (only licenced in children 2 years and above): Otomize® ear spray ONE spray TDS for 7 - 14 days
Gentamicin + steroid ear drops1:
Gentisone HC® TWO to FOUR drops instilled in the affected ear FOUR or FIVE times a day, (including a dose at bedtime) for 7 - 14 days (or equivalent generic product)
If cellulitis and disease extending outside ear canal, start oral antibiotics based on sensitivities
Empirical treatment:
Cefalexin (off-label) for 5 - 7 days
1-11 months: 125mg po BD2
1-4 years: 125mg po TDS2
5-11 years: 250mg po TDS2
12 years and over: 500mg po BD-TDS2
Flucloxacillin1,2 for 5 - 7 days (Note: Oral flucloxacillin (suspension) is extremely unpalatable and is poorly tolerated by the majority of children)
1-23 months: 62.5mg - 125mg po QDS2
2-9 years: 125mg - 250mg po QDS2
10-17 years: 500mg po QDS2
If cellulitis as above and allergic to penicillin (NOTE: incorrectly labelling a child with a penicillin allergy has a lifelong impact on mortality and morbidity (click here for information on correctly applying penicillin labels in children) and/or watch Dr Helen Evans-Howells GP WER Allergy and Simon Williams from Anaphylaxis UK discuss getting the diagnosis correct with drug allergies):
Clarithromycin for 5 - 7 days2
12-17 years: 500mg po BD
Erythromycin (if pregnant) for 5 - 7 days2
8-17 years: 1g po BD
1. NICE & PHE. Summary of antimicrobial prescribing guidance – managing common infections LINK accessed 11/21
2. BNF-C accessed at LINK in November 2021
3. NICE CKS: Otitis externa. Last revised 02/18. Accessed LINK 11/21
4. Malhotra-Kumar S et al. Effect of azithromycin and clarithromycin therapy on pharyngeal carriage of macrolide-resistant streptococci in healthy volunteers: a randomised, double-blind, placebo-controlled study. Lancet. 2007 Feb 10;369(9560):482-90.
Acute otitis media (AOM) resolves in 60% by 24 hours with or without antibiotics, acute complications are rare. Antibiotics only marginally reduce pain at 2 days (NNT 24) and do not prevent deafness. Need to treat 4800 with antibiotics to avoid 1 case of mastoiditis. Antibiotics make little difference to rates of recurrence of infection and perforated ear drum. Adverse events (vomiting, diarrhoea or rash) from antibiotics are significantly increased in children with AOM vs placebo (NNH 13).1
Optimise management of pain - regular paracetamol or ibuprofen for pain (right dose for age or weight at the right time and maximum doses for severe pain).1
Otitis media can be associated with CNS complications, even in young children:
RED FLAGS raising possibility of CNS complications:
Children over 2 years: Only consider starting oral antibiotics if any of the following criteria are met in a child presenting with AOM (bulging ear drum or discharge):
Children aged 6 months-2 years, start antibiotics if any of the following:
Children under 6 months – start antibiotics if presumed AOM
When to consider back up prescription
Consider a back-up / watchful waiting or no prescription in children who do not fit the criteria above, including those with no otorrhoea. It is considered that most children will fall into this category, i.e. not require an immediate prescription.
First line if antibiotics indicated
Amoxicillin for 5 days
Clarithromycin1 for 5 days
Erythromycin (If pregnant)1 for 5 days
If failed on first line (worsening symptoms on first choice taken for at least 2 to 3 days)
Co-amoxiclav for 5 days1
1-11 months: co-amoxiclav 125/31/5ml liquid 0.25mL/kg po TDS 1-5 years: co-amoxiclav 125/31/5ml liquid 5 mL po TDS 6-11 years: co-amoxiclav 250/62/5ml liquid 5 mL po TDS
12-17 years: co-amoxiclav tablets (500/125 mg) 1 po TDS or co-amoxiclav (250/62/5ml) liquid 10 mL po TDS
If penicillin allergy: Send swab and treat in accordance with results. If further advice required consult local microbiologist.
1. NICE NG91 Otitis media (acute): antimicrobial prescribing, 03/18 LINK accessed 09/19
3. Hoberman A et al. Treatment of acute otitis media in children under 2 years of age. N Engl J Med. 2011; 364(2): 105-15. LINK
4. Thompson PL et al. Effect of antibiotics for otitis media on mastoiditis in children: a retrospective cohort study using the United kingdom general practice research database. Pediatrics. 2009; 123(2): 424-30. LINK
5. Valtonen M et al. Comparison of amoxicillin given two and three times a day in acute respiratory tract infections in children. Scand J Prim Health Care. 1986 Nov;4(4):201-4.
6. WHO - Recommendations for management of common childhood 2012 conditions. LINK accessed 11/21
Click here to listen to a podcast on respiratory tract infections in children.
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.
Differentials for the child with cough or respiratory distress include:
If mild severity (child younger than 5 years with absence of persistent / recurrent fever over preceding 24-48 hours, no respiratory distress and no tachypnoea), antibiotics are not indicated. Provide verbal and written safety netting advice.
If moderate severity (persistent / recurrent fever over preceding 24-48 hours, respiratory distress and/or tachypnoea) and presumed diagnosis of CAP (see differentials above), treat with oral antibiotics and provide verbal and written safety netting advice.
In severe disease: Urgent review in hospital required. Features of severe disease include:
* - Parameters for significant tachycardia / tachypnoea:
· Age younger than 6 months: Respiratory rate greater than 70, heart rate greater than 170
· Age 6-11 months: Respiratory rate greater than 70, heart rate greater than 170
· Age 12-35 months: Respiratory rate greater than 50, heart rate greater than 150
· Age 3-4 years: Respiratory rate greater than 50, heart rate greater than 140
· Age 5-13 years: Respiratory rate greater than 40, heart rate greater than 120
· Age 14-17 years: Respiratory rate greater than 30, heart rate greater than 100
Provide written and verbal advice:
First line (if no previous treatment in preceding 4 weeks)
Amoxicillin2,3 for 5 days4
If no response to amoxicillin OR if considered high risk of complications, consider sending a sample for example a sputum sample for microbiological testing (only possible in older chidlren). The sample should be taken before starting the second line antibiotic:
Co-amoxiclav for 5 days2
1-11 months: 125/31/5ml co-amoxiclav liquid 0.5 mL/kg po TDS
1-5 years: co-amoxiclav 125/31/5ml liquid 10 mL po TDS
6-11 years: co-amoxiclav 250/62/5ml liquid 10 mL po TDS
12-17 years: co-amoxiclav tablets (500/125 mg) 1 tablet po TDS or co-amoxiclav 250/62/5ml liquid 10 mL po TDS
Clarithromycin1,3 for 5 days
In pregnancy: Erythromycin2 for 5 days
Sinusitis can be associated with CNS complications. This is rare in children under 8 years old. RED FLAGS raising possibility of CNS complications include:
If a child has these symptoms, consider urgent referral to secondary care (paediatrics)
For children 12 years or older consider prescribing high-dose nasal corticosteroids (equivalent to mometasone 200 micrograms twice a day) for 14 days instead of antibiotics1 (off-label use).
Amoxicillin for 5 days - if no previous antibiotic treatment in preceding 4 weeks
Phenoxymethylpenicillin (Penicillin V)1 for 5 days - Note: The unpleasant taste and palatability of Phenoxymethylpenicillin (Penicillin V) suspension can affect adherence to antibiotics, which may result in treatment failure.
If treatment with amoxicillin in preceding 4 weeks or considered high risk of complications:
Co-amoxiclav for 5 days1,2
1-11 months: co-amoxiclav 125/31/5ml liquid 0.25mL/kg po TDS 1-5 years: co-amoxiclav 125/31/5ml liquid 5 mL po TDS 6-11 years: co-amoxiclav 250/62/5ml liquid 5 mL po TDS 12-17 years: co-amoxiclav tablets (500/125 mg) 1 po TDS or co-amoxiclav (250/62/5ml) liquid 10 mL po TDS
Doxycycline1 for total of 5 days
12 to 17 years: 200mg po on first day, then 100mg OD for 4 days
Erythromycin (if pregnant)1 for 5 days
Provide safety netting information (verbal and written).
Note: aim to use an antibiotic that minimises doing frequency and is palatable (if suspension prescribed) to optimise adherence. QDS penicillin V and flucloxacillin suspensions are not well tolerated by children.
Scabies is rare in children under 2 months of age. Seek specialist advice (e.g. from a paediatric dermatologist) if treatment is required for this age group.
The main symptom is generalised itch – especially at night. Itch may not be apparent in young babies or people with neurological conditions with decreased or loss of sensation. Characteristic silvery lines may be seen in the skin where mites have burrowed. Erythematous papular or vesicular lesions are often associated with the burrows. Typical sites include the interdigital folds, wrists, elbow, penis and scrotum in men and around the nipples in women.
Simultaneously (within 24 hours) treat the infected person and all members of the household, close contacts and sexual contacts even in the absence of symptoms.
Also treat scabies that has become infected with an antibiotic.
Permethrin 5% cream.2 Apply as described below, in two applications, 7 days apart.2 Wash off after 8-12 hours.1,3
Apply the treatment from the chin and ears downwards paying special attention to the areas between the fingers and toes and under the nails.2
In patients under 2 years old and immunosuppressed patients, the insecticide should be applied to the whole body including the face and scalp.1.2
If treatment is washed off with soap within 8 hours of application (e.g. hand washing), it should be reapplied.3
Treatment should be applied to cool, dry skin – not after a hot bath, and allowed to dry before the person dresses in clean clothes.1
If not tolerated or allergy to permethrin or excipients or chrysanthemums
Malathion 0.5% aqueous liquid.2 Apply as described below, in two applications, 7 days apart.2 Wash off after 24 hours.1,3
Apply the treatment to the whole body including the face and scalp, paying special attention to the areas between the fingers and toes and under the nails.2
If treatment is washed off with soap within 24 hours of application (e.g. hand washing), it should be reapplied.3
Seek specialist advice from a consultant dermatologist for the management of anyone presenting with crusted scabies; admission may be required.1
Ask about the person's living conditions, or whether close contacts/family members have also reported itching.1
Itch may persist for up to two weeks after successful treatment. If itching continues for longer than two to four weeks after the last treatment application advise the person to seek follow up.1
Consider symptomatic treatment for itching.
Machine wash (at 60°C or above) clothes, towels, and bed linen, on the day of application of the first treatment. Dry in a hot dryer, or dry cleaning or by sealing in a plastic bag for at least 72 hours.1
If recurrence occurs where all contacts were treated simultaneously and treatment was applied correctly, give a course of a different insecticide. 1
1. NICE CKS Scabies LINK revised 11/17 accessed 07/21
3. BNFc accessed at LINK in 11/21
Threadworms do not always cause symptoms but they can cause extreme itching around the perianal/perineal area particularly at night that can interrupt sleep. The eggs are deposited nocturnally by the adult worms. May be signs of excoriation on examination. Worms may be seen in the perianal area at night. Treat if threadworms have been seen or their eggs have been detected OR if highly suggestive clinical symptoms. All members of the household should be treated at the same time even if asymptomatic (unless treatment is contraindicated).
When to investigate1
If the diagnosis is uncertain or if symptoms persist despite treatment, the adhesive tape test for eggs may be useful – the tape should be examined under a microscope by GP or local laboratory. This may need to be examined on 3 consecutive mornings to confirm diagnosis. Stool samples are not recommended as very few eggs are present in stool. If there are frequent recurrences, consider seeking advice from a paediatrician or a consultant in infectious diseases.
Treatment - all family members should be treated at the same time and household measures to prevent reinfection should be implemented for 2 weeks (see below):
First line treatment for children aged 6 months-17 years1,2,3
Mebendazole 100 mg orally for 1 dose. If reinfection occurs, second dose may be needed after 2 weeks.
Mebendazole is not licensed for use in children under 2 years.
Note: This can be purchased from a pharmacy if the patient is over 2 years of age, in line with NHS OTC consultation.
(Pripsen® (piperazine and senna) is no longer available in the UK).4
First line treatment for children aged younger than 6 months:1
6 weeks strict hygiene (alone) to prevent faecal-oral re-infection2 Continue household measures for 6 weeks if using hygiene measures alone
If recurrent infection – repeat treatment as above. If recurrences occur despite repeat treatment, for Albendazole 400 mg orally (if >2 years of age), with second dose given after 2 weeks. All family should be treated and hygiene measures implemented. If these measures are ineffective, refer to secondary care. Under the direction of secondary care, pulse treatment of a single dose of mebendazole every 14 days for 16 weeks may be considered.
Household measures:
Personal Hygiene:
· Short nails and clean underneath with a brush once a day/ after defaecation. Avoid biting and scratching.
· Wash/shower every morning to remove eggs on skin.
· Always wash hands well with soap and warm water after using bathroom and before eating.
· Wear pants, or tightfitting nightwear in bed and change daily washing at 40ºC or above. Consider wearing cotton gloves at night to avoid scratching.
· Do not share towels
· Do not co-bathe.
Environmental:
· "Hot wash" (>60º) sheets initially and then at least weekly in the morning, do not shake before washing.
· Wearing a face mask and gloves strip the bed and vacuum the mattress and the whole bedroom once a week which again will reduce egg burden and thus minimise the chance of re-infection
· Regularly change bath towels
· Regular cleaning of surfaces
· Fluffy toys in bed should be hot washed
No exclusion from nursery or school is required.1
Child younger than 6 months - add perianal wet wiping or washes three hourly.2
Evidence
Mebendazole does not kill the eggs, eggs can live up to 2 weeks outside the body, therefore adequate personal and environmental hygiene is essential to prevent re-infestation from recently swallowed eggs, or eggs already in the environment.
Evidence for mebendazole is limited based on old, small studies comparing mebendazole with placebo or drugs not available in the UK but it is thought to have a high cure rate3. It has few contraindications and post-marketing surveillance has revealed no serious safety concerns.1
Hygiene measures, plus physical removal advice is based on expert opinion.1
In the event of
1) NICE. Threadworm. Clinical Knowledge Summary. [Online] Last revised Feb 2018. LINK accessed 11/19
2) NICE and PHE. Summary of antimicrobial prescribing guidance – managing common infections LINK accessed 11/19
3) BNFC. [Online] 2020. LINK
4) TOXBASE(R) Threadworm/Pinworm treatment in pregnancy. Date of issue:January 2018, Version: 2.
February 2023: NHSE have reinstated their prescribing guidance for children and young people, because the December 2022 NHSE interim guidance on group A streptococcus that replaced it has been withdrawn. See Group A Streptococcus: withdrawal of NHSE interim guidance.
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. Antibiotic NNT greater than 4000 to prevent one case of quinsy.
Optimise management of pain - regular paracetamol or ibuprofen for pain (right dose for age or weight at the right time and maximum doses for severe pain).1,2
When to send a throat swab:
Diagnosis is primarily a clinical one but a swab should be considered for:
• treatment failure (persistence of clinically relevant symptoms)
• allergic to penicillin (to determine antimicrobial susceptibility)
• diagnostic uncertainty
Base decision about antibiotic treatment on FeverPAIN1,2 score (1 point for each of fever, purulence, attend within 3 days of onset or less, severely Inflamed tonsils, no cough or coryza):
Score validated in children 3 years and over - younger children are less likely than older children to have a bacterial aetiology and are less likely to develop complications.
NOTE: if a child's symptoms are worsening after 3 days, think about other differentials including a peritonsillar abscess (quinsy) or Lemierre syndrome (Fusobacterium).
Amoxicillin for 5 days if Gp A strep tonsillitis suspected (or 10 days if clinical diagnosis of scarlet fever)
Erythromycin (if pregnant)1 for 5 days if Gp A strep tonsillitis suspected and 10 days if clinical diagnosis of scarlet fever
When to treat:
Whenever possible a specimen of urine should be collected for culture and sensitivity testing before starting antibacterial therapy – clean catch if possible. See Healthier Together UTI pathway for information about when to send urine for culture or what to do if UTI suspected but unable to collect a urine specimen. (Image below)
QuickWee method of stimulating suprapubic area with saline-soaked gauze significantly reduces the time taken to successfully collect a urine sample in infants:
For toilet trained children send correctly performed midstream clean catch urine sample. Provide clear instructions to parents/carers.
If unable to tolerate oral antibiotics or systemically unwell (suggestive of bacteraemia) or child under 3 months old, requires URGENT review in hospital for consideration of IV antibiotics – call paediatrician.
Over 3 months of age with LOWER UTI/cystitis
Duration of antibiotic course: 3 days
Trimethoprim (if low risk of resistance)1,2
3-5 months: 4mg/kg po BD (max 200mg per dose) or 25mg po BD1
6 months-5 years: 4mg/kg po BD (max 200mg per dose) or 50mg po BD1
6-11 years: 4mg/kg po BD (max 200mg per dose) or 100mg po BD1
12-15 years: 200mg po BD1
Nitrofurantoin1,2 (Only if child can swallow tablets, previous treatment with trimethoprim in preceding 3 months and eGFR 45ml/min/1.73m2 and over):
3 months-11 years: 750 micrograms/kg po QDS (use immediate release tablets)1
12-17 years: 100mg MR po BD1
Cefalexin2
12.5mg/kg (max 1g per dose) po BD
Or by age:
3-11 months: 125mg po BD1
12-15 years: 500mg po BD1
If confirmed severe penicillin allergy, sensitivities are not known and unable to swallow nitrofurantoin tablets (NOTE: incorrectly labelling a child with a penicillin allergy has a lifelong impact on mortality and morbidity - watch Dr Helen Evans-Howells GP WER Allergy and Simon Williams from Anaphylaxis UK discuss getting the diagnosis correct with drug allergies):
Ciprofloxacin 10mg/kg po BD (max 750mg po BD)3
Over 3 months of age with UPPER UTI / pyelonephritis (all children with a febrile UTI should be considered to have pyelonephritis)
Duration of antibiotic course: 7 days
Empiric treatment: Do not use if unable to tolerate oral antibiotics or systemically unwell (suggestive of bacteraemia)
Cefalexin - all doses off label (higher doses used as pyelonephritis is a severe invasive bacterial infection):
12.5mg/kg (max 1g per dose) TDS
or by age:
3-11 months 125mg po TDS
1- 4 years 250mg po TDS
5-11 years 500mg po TDS
12 years and over 1g po TDS
If confirmed severe penicillin allergy, sensitivities are not known (NOTE: incorrectly labelling a child with a penicillin allergy has a lifelong impact on mortality and morbidity (click here for information on correctly applying penicillin labels in children) and/or watch Dr Helen Evans-Howells GP WER Allergy and Simon Williams from Anaphylaxis UK discuss getting the diagnosis correct with drug allergies):
Ciprofloxacin 10mg/kg po BD (double dose in severe infection) (max 750mg po BD)3
Preventing recurrence
