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.
TREATMENT:
If bite is infected, offer an antibiotic.
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 choices
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
Review child at 24 and 48 hours, as not all pathogens are covered.
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)
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
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
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). 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.
Consider ophthalmia neonatorum in a neonate; this does not refer to a simple “sticky eye” in a neonate and requires urgent review in hospital.
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
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
UPDATE 14/12/22: THERE ARE CURRENTLY SIGNIFICANT SUPPLY CHAIN ISSUES WITH ANTIBIOTIC SUSPENSIONS IN CHILDREN. ALTHOUGH 1ST LINE TREATMENT IS OUTLINED BELOW, ALTERNATIVES INCLUDE CLARITHROMYCIN OR CEFALEXIN (BD DOSING AS PER BNFc). IF THESE DRUGS ARE UNAVAILABLE, THEN CONSIDER CO-AMOXICLAV OR OTHER MACROLIDES SUCH AS AZITHROMYCIN OR ERYTHROMYCIN. IF NONE OF THESE ARE AVAILABLE, CONSIDER CO-TRIMOXAZOLE. For children aged 5 years and over, consider prescribing capsules and signposting to pill swallowing resources; if the child is unable to swallow the capsule, the parent can open the capsule and mix with liquid or soft food (such as yoghurt).
Notify the local health protection team promptly within 3 days by completing a notification form if a diagnosis of scarlet fever is suspected.
For children unable to swallow tablets
Amoxicillin for 5 days if Gp A strep tonsillitis suspected and 10 days if clinical diagnosis of scarlet fever1
40mg/kg po BD4 (max 1g per dose) (off-label)
Or by age:
3-11 months: 125mg po TDS2 or 250mg po BD4 (off-label)
1-4 years: 250mg po TDS2 or 500mg po BD4 (off-label)
5-11 years: 500mg po TDS2 or 750mg po BD4 (off-label)
12 years and over: 500mg po TDS2 or 1g po BD4 (off-label)
Phenoxymethylpenicillin (Penicillin V) for 5 days if Gp A strep tonsillitis suspected and 10 days if clinical diagnosis of scarlet fever1,3
1-11 months: 125mg po BD2
1-5 years: 250mg po BD2
6-11 years: 500mg po BD2
12-17 years: 1g po BD2
For children able to swallow tablets
6-11 years: 500mg po BD2 12-17 years: 1g po BD2
Clarithromycin2,3 for 5 days if Gp A strep tonsillitis suspected 3 and 10 days if clinical diagnosis of scarlet fever
Under 8 kg: 7.5 mg/kg po BD2
8-11 kg: 62.5mg po BD2
12-19 kg: 125mg po BD2
20-29 kg: 187.5mg po BD2
30-40 kg: 250mg po BD2
12-17 years: 250-500mg po BD2
Erythromycin (if pregnant) for 5 days if Gp A strep tonsillitis suspected and 10 days if clinical diagnosis of scarlet fever
8-17 years: 1g po BD2 OR Azithromycin for 3 days if Gp A strep tonsillitis suspected and 5 days if clinical diagnosis of scarlet fever: 6 months-11 years: 12mg/kg po OD (maximum 500mg per dose) 12-17 years: 500mg po OD
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.
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% cream1, 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
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
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: 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
1-4 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
Erythromycin for 5 - 7 days2
1-23 months: 250mg po BD
2-7 years: 500mg po BD
8-17 years: 1g po BD
Clarithromycin for 5 - 7 days2
12-17 years: 500mg 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
40mg/kg po BD (max 1g per dose) (off-label)
1-11 months: 125mg po TDS1 or 250mg po BD6 (off-label)
1-4 years: 250mg po TDS1 or 500mg po BD6 (off-label)
5-11 years: 500mg po TDS1 or 750mg po BD6 (off-label)
12 years and over: 500mg po TDS1 or 1g po BD6 (off-label)
Clarithromycin for 5 days1
Erythromycin for 5 days1
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 3 days4
40mg/kg po BD (max 1g per dose) (off-label)5
3-11 months: 125mg po TDS2 or 250mg po BD5 (off-label)
1-4 years: 250mg po TDS2 or 500mg po BD5 (off-label)
5-11 years: 500mg po TDS2 or 750mg po BD5 (off-label)
12 years and over: 500mg po TDS2 or 1g po BD5 (off-label)
If no response to amoxicillin OR if considered high risk of complications
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
If allergic to penicillin OR if no response to first line empirical therapy
Clarithromycin1,3 for 5 days
Erythromycin2 for 5 days
1-23 months: 250mg po BD6
2-7 years: 500mg po BD6
8-17 years: 1g po BD6
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).
First line antibiotics
Amoxicillin for 5 days - if no previous antibiotic treatment in preceding 4 weeks
40mg/kg po BD6 (max 1g per dose) (off-label)
Or by age 3-11 months: 125mg po TDS2 or 250mg po BD6 (off-label) 1-4 years: 250mg po TDS2 or 500mg po BD6 (off-label) 5-11 years: 500mg po TDS2 or 750mg po BD6 (off-label) 12 years and over: 500mg po TDS2 or 1 gram po BD6 (off-label)
Phenoxymethylpenicillin (Penicillin V) for 5 days
1-11 months: 62.5mg po QDS1 or 125mg po BD (off-label) 1-5 years: 125mg po QDS1 or 250mg po BD (off-label) 6-11 years: 250mg po QDS1 or 500mg po BD (off-label) 12-17 years: 500mg po QDS1 or 1g po BD (off-label)
If treatment with amoxicillin in preceding 4 weeks or consider 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
30-40 kg: 250mg po BD 12-17 years: 500mg po BD
Doxycycline1 for total of 5 days
12 to 17 years: 200mg po on first day, then 100mg OD for 4 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.
It can sometimes be challenging for children to swallow large volumes of suspensions. Most school age children (from above 4 years of age) can be taught to swallow tablets. The following website provides great information for parents on teaching their child to swallow tablets - www.pillswallowing.com
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. Treat if threadworms have been seen or their eggs have been detected. 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, 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. If there are frequent recurrences, consider seeking advice from a paediatrician or a consultant in infectious diseases.
In conjunction with treatment, advise rigorous hygiene measures for 2 weeks (hand hygiene, cutting fingernails regularly, avoid biting nails and scratching around anus, wearing close fitting pants at night, morning shower including washing of the perianal area). Avoid sharing towels and flannels. This should be continued for 2 weeks if treated with mebendazole and 6 weeks if using hygiene measures alone.
PLUS wash sleepwear and bed linen daily for several days after treatment and thoroughly dust and vacuum (including mattresses) and clean bathroom.
No exclusion from nursery or school is required.1
Child younger than 6 months - add perianal wet wiping or washes three hourly.2
Treatment:
First line 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 for children aged younger than 6 months:1
6 weeks strict hygiene (alone) to prevent faecal-oral re-infection2
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
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.
There are currently extremely high rates of Gp A streptococcus in children (esp aged less than 5 years). Prescribers should adopt a lower threshold for antibiotic prescribing in children with tonsilltis at this current time. Prescribers should use clinical judgement and the FeverPAIN scoring system to decide if antibiotics are required; a score of 3 or more (esp in the absence of other upper respiratory tract signs such as rhinorrhoea) should warrant the prescribing of antibiotics. In children aged <3 years of age, the presence of fever and purulent tonsils, in the absence of coryzal symptoms also merits the prescribing of antibiotics. A more conventional approach to managing children with tonsillitis will be resumed when the rate of Group A streptococcus falls.
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
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.
NOTE: if a child's symptoms are worsening after 3 days, think about other differentials including a peritonsillar abscess (quinsy) or Lemierre syndrome (Fusobacterium).
Most children with tonsillitis do not require a throat swab. Send a throat swab if treatment failure and reattendance
Amoxicillin for 5 days if Gp A strep tonsillitis suspected and 10 days if clinical diagnosis of scarlet fever
3-11 months: 125mg po TDS3 or 250mg po BD4 (off-label)
1-4 years: 250mg po TDS3 or 500mg po BD4 (off-label)
5-11 years: 500mg po TDS3 or 750mg po BD4 (off-label)
12 years and over: 500mg po TDS3 or 1g po BD4 (off-label)
Phenoxymethylpenicillin (Penicillin V)1 for 5 days if Gp A strep tonsillitis suspected and 10 days if clinical diagnosis of scarlet fever
1-11 months: 125 mg po BD
1-5 years: 250 mg po BD
6-11 years: 500 mg po BD
12-17 years: 1g po BD
Phenoxymethylpenicillin (Penicillin V)1 for 5 days
12 years or over: 1g po BD
Clarithromycin1 for 5 days if Gp A strep tonsillitis suspected and 10 days if clinical diagnosis of scarlet fever
Erythromycin for 5 days if Gp A strep tonsillitis suspected and 10 days if clinical diagnosis of scarlet fever
1-23 months: 250mg po BD3
2-7 years: 500mg po BD3
8-17 years: 1g po BD1,3
OR Azithromycin for 3 days if Gp A strep tonsillitis suspected and 5 days if clinical diagnosis of scarlet fever 6 months-11 years: 12mg/kg po OD (maximum 500mg per dose) 12-17 years: 500mg po OD
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
Cefalexin – all doses off label2
12.5mg/kg (max 1g per dose) po BD
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
Ciprofloxacin 10mg/kg po BD (double dose in severe infection) (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
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
Preventing recurrence
