Empirical antibiotic guidelines for children

Acne Vulgaris

Guidance for children aged 12 years and over

When to investigate¹

Urgently refer people with acne fulminans (very serious form of acne conglobata associated with systemic symptoms) on the same day to the on-call hospital dermatology team, to be assessed within 24 hours.

Refer people to a consultant dermatologist-led team if:

There is diagnostic uncertainty.
They have acne conglobate (severe form of nodulo-cystic acne with interconnecting sinuses and abscesses).
They have nodulo-cystic acne.

Consider referring people to a consultant dermatologist-led team if:

Mild to moderate acne has not responded to two completed courses of treatment.
Moderate to severe acne has not responded to previous treatment that includes an oral antibiotic.
They have acne with scarring.
They have acne with persistent pigmentary changes.
Their acne of any severity, or acne-related scarring, is causing or contributing to persistent psychological distress or a mental health disorder.

Consider referring people to mental health services if a person with acne experiences significant psychological distress or a mental health disorder, including those with a current or past history of:

Suicidal ideation or self-harm.
A severe depressive or anxiety disorder.
Body dysmorphic disorder.

Consider condition-specific management or referral to a specialist (e.g.to endocrinology or gynaecology, women suspected of having an underlying endocrinological cause of acne), if a medical disorder or medication is likely to be contributing to acne (including considering anabolic steroid use).

Definitions¹

Mild to moderate acne: one or more of:

Any number of non-inflammatory lesions (comedones).
Up to 34 inflammatory lesions (with or without non-inflammatory lesions).
Up to 2 nodules.

Moderate to severe acne: one or more of:

35 or more inflammatory lesions (with or without non-inflammatory lesions).
3 or more nodules.

General advice¹

Advise people to avoid over cleaning the skin i.e. not to wash more than twice a day, use a mild soap or cleanser and lukewarm water.
Advise people with acne to use a non-alkaline (skin pH neutral or slightly acidic) synthetic detergent (syndet) cleansing product twice daily on acne-prone skin.
Avoid oil-based and comedogenic skin care products, make-up and sunscreens.
Advise people that persistent picking or scratching of acne lesions can increase the risk of scarring.
Treatments are effective but take time to work (typically 6-8 weeks) and may irritate the skin, especially at the start of treatment. Completing the course is important because positive effects can take 6 to 8 weeks.
To reduce the risk of skin irritation associated with topical treatments, such as benzoyl peroxide or retinoids, start with alternate-day or short-contact application (for example washing off after an hour). If tolerated, progress to using a standard application.
Concentration or application frequency of topical treatments may need to be reduced or lowered if skin irritation occurs.
The risk of scarring increases with the severity and duration of acne.
Topical retinoids and oral tetracyclines are contraindicated during pregnancy and when planning a pregnancy. The person will need to use effective contraception, or choose an alternative treatment to these options.
For people with acne-related scarring, discuss their concerns and provide information, including:
- Possible reasons for their scars.
- Treatment of ongoing acne to help prevent further scarring.
- Possible treatment options for acne-related scarring.
- The way their scars may change over time.
- Psychological distress.
- Refer to a consultant dermatologist-led team with expertise in scarring management if acne-related scarring is severe and persists a year after acne has cleared.

Treatment choices

First line treatment options:

Offer a course of 1 of the options below, taking account of severity, preferences, advantages/disadvantages of each option and if the patient is pregnant or breastfeeding.

The following should not be used to treat acne:^1,3

Monotherapy with a topical antibiotic.
Monotherapy with an oral antibiotic.
A combination of a topical antibiotic and an oral antibiotic.

Mild to moderate acne^1,2,3

First line: Offer a 12 week course of one of the following options to be applied thinly every night:

Fixed combination of topical adapalene (0.1% or 0.3%) with topical benzoyl peroxide (2.5%) i.e. Epiduo^®
Fixed combination of topical benzoyl peroxide (3% or 5%) with topical clindamycin (1%) i.e. Duac Once Daily gel ® or equivalent generic product
Fixed combination of topical tretinoin* (0.025%) with topical clindamycin (1%) i.e. Treclin^®(NOT to be used in pregnant women)

* Topical retinoids are contraindicated in pregnancy and when planning a pregnancy. The person will need to use effective contraception. Advise with topical retinoids to protect skin from sunlight, even on a bright but cloudy day.

When developing treatment plan take into account severity of acne, the person's preferences and have a discussion of the advantages and disadvantages of each option.

Second line: Consider topical benzoyl peroxide 5% OD to BD as monotherapy as an alternative if the above are contraindicated or the person wishes to avoid using topical retinoids and antibiotics (topical or oral).

Moderate to severe acne^1,2,3

First line: Offer a 12 week course of one of the following options, taking account of the severity of acne, the person’s preferences and after a discussion of the advantages and disadvantages of each option:

Fixed combination of topical adapalene (0.1% or 0.3%) with topical benzoyl peroxide (2.5%) applied thinly every night i.e. Epiduo
Fixed combination of topical tretinoin* (0.025%) with topical clindamycin (1%) applied every night i.e. Treclin (NOT to be used in pregnant women)
Fixed combination of topical adapalene (0.1% or 0.3%) with benzoyl peroxide (2.5%) applied thinly every night i.e. Epiduo

PLUS either lymecycline 408mg po OD OR doxycycline^# 100mg po OD (doxycycline NOT to be used in pregnant women)

Topical azelaic acid (15% Finacea gel or 20% Skinoren cream) applied BD PLUS either lymecycline 408mg po OD OR doxycycline^# 100mg po OD (doxycycline NOT to be used in pregnant women)

# Doxycycline is contraindicated in pregnancy.

Third line: For those who cannot tolerate / have contraindications to oral lymecycline and doxycycline, consider replacing these in the regimens with trimethoprim or macrolide.

Combined oral contraceptive alternatives for management of acne in females¹

Third and fourth-generation combined oral contraceptive pill are generally preferred for the hormonal management of acne (progesterone-only contraceptives or progestin implants with androgenic activity may exacerbate acne).

Co-cyprindiol (or other ethinylestradiol / cyproterone-containing products) may be considered in moderate to severe acne where other treatments have failed, but require careful discussion of the risks and benefits with the patient.

Use should be discontinued 3 months after acne has been controlled.

Relapse¹

If acne responds adequately to a course of an appropriate first-line treatment but then relapses, consider either:

Another 12-week course of the same treatment OR
An alternative 12-week treatment

Link to patient information leaflet

British Association of Dermatologists

References

1. NICE; NG198. Acne vulgaris: management. Published 06/21 LINK accessed 11/21

2. BNF. LINK accessed 11/21

3. PHE. Summary of antimicrobial prescribing guidance: managing common infections LINK last updated 05/21, accessed 11/21

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:

Jan 2024

www.drhelenallergy.co.uk

Bites (animal and human)

When to treat

Assess the severity of the bite:

Site and depth of wound
Whether it is infected

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:

Unable to irrigate and debride wound sufficiently
Unable to close the wound

Consider referral or seeking specialist advice if the person:

Is systemically unwell or has signs or symptoms remote from the bite
Has an infection after prophylactic antibiotics
Cannot take, or has an infection that is not responding to, oral antibiotics

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. For children aged 5 years and over requiring treatment with antibiotics, consider prescribing tablets/capsules and signposting to pill swallowing information on the Healthier Together website or Medicines for Children website. If the child is unable to swallow the tablets/capsules see the advice from Specialist Pharmacy Service (SPS) about using solid oral dosage form antibiotics in children (https://www.sps.nhs.uk/articles/using-solid-oral-dosage-form-antibiotics-in-children/).

Establish what has caused the bite and select appropriate action below.

Reassess if:

Symptoms or signs of infection develop or worsen rapidly or significantly at any time
There is no improvement within 24 - 48 hours of starting treatment
The person becomes systemically unwell
There is severe pain that is out of proportion to the infection

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 blood^1,2

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

Is to high risk area e.g. hands, feet, face, genitals, skin overlying cartilaginous structures or an area of poor circulation
Is in a person at high risk of serious wound infection due to co-morbidities such as diabetes, immunosuppression, asplenia or decompensated liver disease or presence of prosthetic valve/joint

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.

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:

Is to high risk area e.g. hands, feet, face, genitals, skin overlying cartilaginous structures or an area of poor circulation
Is in a person at high risk of serious wound infection due to co-morbidities such as diabetes, immunosuppression, asplenia or decompensated liver disease

Do NOT offer antibiotics if the bite has broken skin but not drawn blood.^1,2

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 Public Health Team (UKHSA) 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 investigate^1,2

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 treatment^1,3

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 penicillin^1,3- 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)

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 days for treatment.

PLUS

Metronidazole 400mg po TDS for 3 days for prophylaxis or 5 days for treatment^1,2

General advice

Advise patient to seek medical help if an infection:

Develops or worsens rapidly or significantly at any time
Does not start to improve within 24 to 48 hours of starting treatment

* These medications can be implicated in C. diff infection. However, this is extremely rare in children. See Foreword if more information is needed.

References

NICE. Human and animal bites: antimicrobial prescribing [NG184]. 11/20. Accessed at LINK 11/21
Antibiotic and diagnostic quick reference tools: Summary of antimicrobial prescribing guidance – managing common infections. RCGP Learning. Accessed at LINK 11/21
BNFc accessed at LINK 11/21

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

Jan 2024

Candidiasis (oral)

When to treat

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

For children aged 5 years and over requiring treatment with systemic antifungal therapy, consider prescribing tablets/capsules and signposting to pill swallowing information on the Healthier Together website or Medicines for Children website.

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 QDS²after 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

Advice on adminstering ⁴;

Shake the medicine well. Measure out the right amount using an oral syringe or medicine spoon. You can get these from your pharmacist. Do not use a kitchen teaspoon as it will not give the right amount.
Put the medicine into your child’s mouth. They should keep it in their mouth for as long as possible – the longer it is in contact with the infected area, the better it will work.
Your child should then swallow or spit out the medicine, depending on what your doctor has told you to do.
Do not dilute the medicine or mix it with food or drink.

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 once only

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 fluconazole using BNFc or Summary of Product Characteristics.

Safety netting

Healthier Together website link for Thrush - this is aimed at infants under 3 months only

References

Antibiotic and diagnostic quick reference tools: Summary of antimicrobial prescribing guidance – managing common infections. RCGP Learning. Accessed at LINK 02/23
BNFc LINK accessed 02/23
Antimicrobial paediatric prescribing summary for hospitals; UK PAS group LINK last updated 2/22, accessed 02/23
Medicines for children. Nystatin for candida infections.Patient information leaflet LINK accessed 02/23

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

Jan 2024

Cellulitis

When to treat

Refer all severe cases for hospital treatment.

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).

If the patient is afebrile and tolerating oral antibiotics, they can be managed in primary care. Caution with immunocompromised patients.

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.

When to investigate

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 testing.

Safety netting

Provide verbal and written advice

Treatment choices

For children aged 5 years and over requiring treatment with systemic antibiotics, consider prescribing tablets/capsules and signposting to pill swallowing information on the Healthier Together website or Medicines for Children website. If the child is unable to swallow the tablets/capsules see the advice from Specialist Pharmacy Service (SPS) about using solid oral dosage form antibiotics in children (https://www.sps.nhs.uk/articles/using-solid-oral-dosage-form-antibiotics-in-children/).

Impetigo

Localised non-bullous impetigo (≤3 lesions/clusters present)

Use a topical antiseptic, such as Hydrogen peroxide 1% cream^1,4, applied BD-TDS¹,^2,4 for 5-7 days^{1,2, 4}Crystacide^®

If Hydrogen peroxide unsuitable or ineffective use topical antibiotics:

First choice: Fusidic acid 2% cream TDS for 5-7 days^1,2.4

Alternative: if Fusidic acid resistant suspected or confirmed: Mupirocin 2% ointment¹ TDS for 5-7 days^1,2,4

Widespread non-bullous or bullous impetigo with systemic symptoms (≥4
lesions/clusters present)

Use oral antibiotics as below (treat as cellulitis)

Cellulitis

First line

Flucloxacillin for 5-7 days^1,3,4 Note: The unpleasant taste and palatability of flucloxacillin suspension can affect adherence to antibiotics, which may result in treatment failure.

1 month-23 months: 62.5-125mg po QDS³

2 years-9 years: 125-250mg po QDS³

10 years-17 years: 250-500mg po QDS³

Cefalexin² for 5-7 days*

1 month up to 12 years: 12.5mg/kg po BD²

1 month-11 months: 125mg po BD²

1 year-4 years: 125mg po TDS²

5 years-11 years: 250mg po TDS²

12 years and over: 500mg po BD-TDS²

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)

Clarithromycinfor 7 days³

Weight-based for 1 month to 11 years:

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 years to 17 years: 500mg po BD

Erythromycin (if pregnant)³

8 years-17 years: 250mg-500mg po QDS³

Facial cellulitis

If severe facial cellulitis, refer to secondary care.

Co-amoxiclav^1,2,3for 7 days³*

1 month-11 months: co-amoxiclav 125/31/5ml liquid 0.25 mL/kg po TDS³

1 year-5 years: co-amoxiclav 125/31/5ml liquid 5 mL po TDS (dose doubled in severe infection)³

6 years-11 years: co-amoxiclav 250/62/5ml liquid 5 mL po TDS (dose doubled in severe infection)³

12 years-17 years co-amoxiclav tablets (500/125 mg) 1 tablet po TDS or co-amoxiclav 250/62/5ml liquid 10 mL po TDS³

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)

Clarithromycinfor 7 days³

Weight-based for 1 month to 11 years:

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 years to 17 years: 500mg po BD

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 years-17 years: 400mg po TDS

Cautions

Aim to use an antibiotic that minimises dosing frequency and is palatable (if suspension prescribed)to optimise adherence.

* These medications can be implicated in C. diff infection. However, this is extremely rare in children. See Foreword if more information is needed.

References

Antibiotic and diagnostic quick reference tools: Summary of antimicrobial prescribing guidance – managing common infections. RCGP Learning. Accessed at LINK 11/21
BNFc accessed at LINK 02/23
NICE (2019). Cellulitis and erysipelas: antimicrobial prescribing.[NG141] 09/19. Accessed at LINK 11/21.
NICE (2020). Impetigo: antimicrobial prescribing.[NG153] 02/20. Accessed at LINK 11/21

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

Jan 2024

Conjunctivitis

When to treat

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

First line

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 line

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)²

PLUS Chloramphenicol eye ointment 1% (Apply at night)³

Continue until 2 days after symptoms resolved.²

Note: Both drops and ointment are licensed for sale (Legal category [P]) for the treatment of acute bacterial conjunctivitis for adults and children over 2 years old.

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.

General advice

Advise patient about self-management:

Exercise hand hygiene and avoid sharing towels or pillows
Avoid contact lenses until symptoms have cleared
United Kingdom Health Security Agency (UKHSA) advises that it is not necessary to stay away from school unless the patient is feeling particularly unwell: https://www.nhs.uk/conditions/conjunctivitis/#work-and-school

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.

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

References

NICE CKS. Conjunctivitis – infective. Last revised 04/21. Accessed at LINK 4/21
BNFc accessed at LINK 02/23
Antibiotic and diagnostic quick reference tools: Summary of antimicrobial prescribing guidance – managing common infections. RCGP Learning. Accessed at LINK 02/23
Management of acute infective conjunctivitis. Drug and Therapeutics Bulletin 2011; 49(7): 78-80 LINK

Last updated

Jan 2024

Fungal skin and nail infections

DERMATOPHYTE INFECTION - SKIN / SCALP

When to treat

The diagnosis of suspected fungal infection of the body and groin should be made on the basis of clinical features.¹

Scalp infection (tinea capitis) should be discussed with specialist.¹

When to investigate

Send skin scrapings if intractable infection or infection of the scalp.^2,3

General advice

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

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

Oral terbinafine

Scalp

Oral terbinafine (dosing as below). If not responding after 4-6 weeks, review. Refer if no regeneration of hair to a specialist.

Body

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

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.

References

NICE CKS. Fungal skin infection – body and groin. Last revised 05/18. Available via LINK accessed 11/21
Antibiotic and diagnostic quick reference tools: Summary of antimicrobial prescribing guidance – managing common infections. RCGP Learning. Accessed at LINK 11/21
NICE CKS. Fungal skin infection – scalp. Last revised 04/18. Available via LINK accessed 11/21
BNFc accessed LINK 02/23
NICE CKS. Candida – skin. Last revised 05/17. Available via LINK accessed 11/21
NICE CKS. Fungal skin infection – foot. Last revised 04/18. Available via LINK. accessed 11/21

DERMATOPHYTE INFECTIONS (NAILS)

When to treat

Take nail clippings. Start therapy only if infection is confirmed.¹

Treatment choices

Oral terbinafine.

Terbinafine² 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

6 week treatment course for fingernails, 12 weeks for toenails¹

If prescribing oral terbinafine: monitor LFTs before treatment and then periodically after 4-6 weeks of treatment. Discontinue if abnormalities in liver function tests.²

Check drug interactions and contraindications when prescribing oral terbinafine using BNFc or Summary of Product Characteristics.

If not responding after 6-12 weeks, review and seek dermatology specialist advice.

References

NICE Management of fungal nail infections (https://cks.nice.org.uk/topics/fungal-nail-infection/management/management/) LINK accessed 01/24
Antibiotic and diagnostic quick reference tools: Summary of antimicrobial prescribing guidance – managing common infections. RCGP Learning. Accessed at LINK 02/23
BNFc accessed LINK 02/23

Last updated

Jan 2024

Group A strep and scarlet fever

When to refer¹

If signs of sepsis, refer to Sepsis Pathway
If suspicion of invasive group A streptococcal infections (quinsy, severe cellulitis, pneumonia with empyema, lymph node abscess, mastoiditis, orbital cellulitis, septic arthritis/osteomyelitis or sepsis) refer URGENTLY to hospital.

When to treat²

Scarlet fever remains a clinical diagnosis. First symptoms often include a sore throat, headache, fever, nausea and vomiting.

After 12 to 48 hours the characteristic fine red rash develops (if you touch it, it feels like sandpaper). Typically, it first appears on the chest and stomach, rapidly spreading to other parts of the body. On more darkly-pigmented skin, the rash may be harder to spot, although the ‘sandpaper’ feel should be present.

Further symptoms include:

• fever over 38.3º C (101º F) or higher is common

• white coating on the tongue which peels a few days later, leaving the tongue looking red and swollen (known as ‘strawberry tongue’)

• swollen glands in the neck

• feeling tired and unwell

• flushed red face, but pale around the mouth. The flushed face may appear more ‘sunburnt’ on darker skin

• peeling skin on the fingertips, toes and groin area, as the rash fades.

General advice¹

Advise the family to keep child away from school/nursery for 1 day after starting antibiotic treatment, wash their hands frequently, avoid sharing eating utensils and towels, dispose of tissues promptly, and avoid contact with anyone at particular risk of infection (e.g. people with valvular disease or who are immunocompromised).

Safety netting

Strep A and Scarlet fever written and verbal advice from Healthier Together

Testing

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)²

• diagnostic uncertainty²

For UK HSA guidance on the role of point of care streptococcal tests, click here.

Treatment choices

For children aged 5 years and over requiring treatment with antibiotics, consider prescribing tablets/capsules and signposting to pill swallowing information on the Healthier Together website or Medicines for Children website. If the child is unable to swallow the tablets/capsules see the advice from Specialist Pharmacy Service (SPS) about using solid oral dosage form antibiotics in children (https://www.sps.nhs.uk/articles/using-solid-oral-dosage-form-antibiotics-in-children/).

For children unable to swallow tablets

Phenoxymethylpenicillin (Penicillin V) for 10 days^1,4 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: 125mg po BD⁶

1 years-5 years: 250mg po BD⁶

6 years-11 years: 500mg po BD⁶

12 years-17 years: 1g po BD⁶

OR alternative is

Amoxicillin for 10 days

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 BD⁵ (max 1g per dose) could be considered. This is off-label^7,8,9

For children able to swallow tablets

Phenoxymethylpenicillin (Penicillin V) tablets for 10 days^1,4

6 years-11 years: 500mg po BD⁶
12 years-17 years: 1g po BD⁶

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)

Clarithromycin⁴for 10 days¹

Weight-based for 1 month to 11 years:

Under 8 kg: 7.5 mg/kg po BD

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 years-17 years: 250mg-500mg po BD

Erythromycin (if pregnant) for 10 days

8 years-17 years: 1g po BD⁶ (off-label)

Cautions

Aim to use an antibiotic that minimises dosing frequency and is palatable (if suspension prescribed)to optimise adherence.

Useful resources

The following NICE resources helpful, as well as information for parents available via the Healthier Together and NHS websites may be helpful:

• Fever in under 5s: assessment and initial management [NG143]

• Sore throat – acute [CKS]

• Scarlet Fever [CKS]

• Sepsis: recognition, diagnosis and early management [NG51]

The following UKHSA resources may be helpful:

• https://www.gov.uk/government/collections/scarlet-fever-guidance-and-data

• https://www.gov.uk/government/collections/group-a-streptococcal-infections-guidance-and-data

References

NICE CKS. Scarlet fever. Last revised December 2022. Accessed LINK 02/23
UKHSA, NICE, Royal Pharmaceutical Society, RCPCH, RCGP and NHSE.Group A streptococcus in children, interim clinical guidance summary. 9/12/22
BNFc accessed at LINK 02/23
Antibiotic and diagnostic quick reference tools: Summary of antimicrobial prescribing guidance – managing common infections. RCGP Learning. Accessed at LINK 02/23
WHO - Recommendations for management of common childhood 2012 conditions. LINK accessed 02/23
NICE NG84, Sore throat (acute): antimicrobial prescribing. 01/18 LINK date accessed 20/2/23
Fonseca W et al. Comparing pharmacokinetics of amoxicillin given twice or three times per day to children older than 3 months with pneumonia. Antimicrob Agents Chemother. 2003 Mar;47(3):997-1001.
Vilas-Boas AL et al. PNEUMOPAC-Efficacy Study Group. Comparison of oral amoxicillin given thrice or twice daily to children between 2 and 59 months old with non-severe pneumonia: a randomized controlled trial. J Antimicrob Chemother. 2014 Jul;69(7):1954-9.
Daschner FD et al. Prospective clinical trial on the efficacy of amoxycillin administered twice or four times daily in children with respiratory tract infections. J Int Med Res. 1981;9(4):274-6.

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

Jan 2024

Impetigo

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.

When to investigate

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 testing.

Safety netting

Provide verbal and written advice

Treatment choices

Impetigo

Localised non-bullous impetigo (≤3 lesions/clusters present)

Use a topical antiseptic, such as Hydrogen peroxide 1% cream^1,4, applied BD-TDS¹,^2,4 for 5-7 days^{1,2, 4}Crystacide^®

If Hydrogen peroxide unsuitable or ineffective use topical antibiotics:

First choice: Fusidic acid 2% cream TDS for 5-7 days^1,2.4

Alternative: if Fusidic acid resistant suspected or confirmed: Mupirocin 2% ointment¹ TDS for 5-7 days^1,2,4

Widespread non-bullous or bullous impetigo with systemic symptoms (≥4 lesions/clusters present)

Treat with oral antibiotics:

First line

Flucloxacillin for 5-7 days^1,3,4 Note: The unpleasant taste and palatability of flucloxacillin suspension can affect adherence to antibiotics, which may result in treatment failure.

1 month-23 months: 62.5-125mg po QDS³

2 years-9 years: 125-250mg po QDS³

10 years-17 years: 250-500mg po QDS³

Cefalexin² for 5-7 days*

1 month up to 12 years: 12.5mg/kg po BD²

1 month-11 months: 125mg po BD²

1 year-4 years: 125mg po TDS²

5 years-11 years: 250mg po TDS²

12 years and over: 500mg po BD-TDS²

Clarithromycinfor 7 days³

Weight-based for 1 month to 11 years:

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 years to 17 years: 500mg po BD

Erythromycin (if pregnant)³

8 years-17 years: 250mg-500mg po QDS³

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

Jan 2024

Insect bites

When to treat

Most insect bites or stings will not need antibiotics.¹

Consider advising or prescribing antihistamines 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 & Impetigo (CHILDREN)

References

1. NICE. Insect bites and stings: antimicrobial prescribing. [NG182]. September 2020. Accessed at LINK 2/23

2. Antibiotic and diagnostic quick reference tools: Summary of antimicrobial prescribing guidance – managing common infections. RCGP Learning. Accessed at LINK 02/23

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

Jan 2024

Lymphadenitis

When to treat

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:

- Stertor or stridor suggesting airway obstruction
- Difficulty swallowing/drooling
- Muffled speech
- Torticollis (can occur in minor infections but potential sign of retropharyngeal infection)
- Severe respiratory distress
- Haemodynamic instability / sepsis (may require urgent source control)

Safety netting

Provide verbal and written advice

Treatment choices

If mild/moderate infection

Cefalexin³ for 7 days*

1 month-11 months: 125mg po BD¹

1 year-4 years: 125mg po TDS¹

5 years-11 years: 250mg po TDS¹

12 years and over: 500mg po BD-TDS¹

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)

Clarithromycin1,3 for 7 days

Weight-based for 1 month to 11 years:

Under 8 kg: 7.5mg/kg po BD

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 years - 17 years: 500mg po BD

Cautions

Aim to use an antibiotic that minimises dosing frequencyand is palatable (if suspension prescribed)to optimise adherence.

* These medications can be implicated in C. diff infection. However, this is extremely rare in children. See Foreword if more information is needed.

References

1. BNFc accessed at LINK 02/23

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 2/22, accessed 02/23

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

Jan 2024

Otitis Externa

When to treat

If cellulitis and disease extending outside ear canal, start oral antibiotics based on sensitivities and arrange urgent ENT review.

Treatment choices

First line

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 licensed for children 2 years and over): 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 month upto 12 years: 12.5mg/kg po BD²

1 month-11 months: 125mg po BD²

1 year-4 years: 125mg po TDS²

5 years-11 years: 250mg po TDS²

12 years and over: 500mg po BD-TDS²

Flucloxacillin^1,5 for 5 - 7 days⁵ - Note: The unpleasant taste and palatability of flucloxacillin suspension can affect adherence to antibiotics, which may result in treatment failure.

1 month-23 months: 62.5mg - 125mg po QDS^2,5

2 years-9 years: 125mg - 250mg po QDS^2,5

10 years-17 years: 500mg po QDS^2,5

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)

Clarithromycin for 5 - 7 days^2,5

Weight-based for 1 month to 11 years:

Under 8 kg: 7.5mg/kg po BD

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 years-17 years: 500mg po BD

Erythromycin for 5 - 7 days² (for pregnant patients)

8 years-17 years: 250 mg to 500 mg QDS

Safety netting

Provide verbal and written advice

Cautions

Aim to use an antibiotic that minimises dosing frequency and is palatable (if suspension prescribed)to optimise adherence. The unpleasant taste and palatability of flucloxacillin suspension can affect adherence to antibiotics, which may result in treatment failure.

* These medications can be implicated in C. diff infection. However, this is extremely rare in children. See Foreword if more information is needed.

Evidence

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

References

Antibiotic and diagnostic quick reference tools: Summary of antimicrobial prescribing guidance – managing common infections. RCGP Learning. Accessed at LINK 02/23
BNF-C accessed at LINK 2/23
NICE CKS: Otitis externa. Last revised 02/18. Accessed LINK 11/21
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.
NICE. 2019. Cellulitis and erysipelas: antimicrobial prescribing [NG141]. LINK Accessed 2/23

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

Jan 2024

Otitis Media

When to treat

Acute otitis media (AOM) resolves in 60% of cases 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:

Severe headache persisting despite regular analgesia (ibuprofen and paracetamol) or worse on lying down / in morning
Severe retroorbital pain
Persistent vomiting
New onset squint or diplopia - covering up one eye
Deteriorating vision - complaining of blurred vision
New limb weakness – may exhibit change of hand preference
Unsteady gait or coordination issues
Increasing drowsiness
Meningism / irritability

When to treat with antibiotics

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):

Symptoms not improving after 3 days¹
Purulent discharge from ear canal (not due to otitis externa) (otorhoea)¹
Systemically unwell¹
Has high risk of complications¹

Children aged 6 months-2 years: in addition to indications above, start antibiotics if bilateral AOM.

Children under 6 months: start antibiotics if a 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.

When no antibiotic prescription is given, give advice about:

An antibiotic not being needed
Seeking medical help if symptoms worsen rapidly or significantly, do not start to improve after 3 days, or the child or young person becomes systemically very unwell

When a back-up antibiotic prescription is given, give advice about:

An antibiotic not being needed immediately
Using the back-up prescription only if symptoms do not start to improve within 3 days or if they worsen at any time
Seeking medical help if symptoms worsen rapidly or significantly, or the child or young person becomes systemically very unwell

Safety netting

Provide verbal and written advice

Treatment choices

If immediate oral antibiotics are not required (if on local formulary)

Eardrops containing an anaesthetic and an analgesic may be considered if this has been approved within your local formulary. Use only if an immediate oral antibiotic prescription is not given, and there is no eardrum perforation or otorrhoea.

Otigo^® (Phenazone 40 mg/g with Lidocaine 10 mg/g): Instil 4 drops BD – TDS into the external auditory canal of the affected ear, slightly pressing the elastic part of the dropper, for up to 7 days¹

Review treatment if symptoms do not improve within 7 days or worsen at any time.

To avoid the unpleasant contact of the ear with the cold solution, warm the vial before use between your hands.

First line treatment if antibiotics indicated

Amoxicillin¹ for 5 days

By age
1 month-11 months: 125mg po TDS¹
1 year-4 years: 250mg po TDS¹
5 years and over: 500mg po TDS¹
Where TDS dosing is impractical: 40mg/kg po BD⁶ (max 1g per dose) could be considered. This is off-label^7,8,9

If you are unable to access amoxicillin suspension consider if the patient can swallow capsules (signpost parent/carer to the pill swallowing information on the Healthier Together website or Medicines for Children website). If swallowing capsules is not possible see the advice from Specialist Pharmacy Service (SPS) about using solid oral dosage form antibiotics in children.

When looking at the SPS guidance about using solid oral dosage form antibiotics in children be aware of the statement that 'Use in this way is outside the product license (‘off-label’)' and the statements related to allergies of those crushing tablets or opening capsules.

Clarithromycin for 5 days¹

Weight-based for 1 month to 11 years:

Under 8 kg: 7.5mg/kg po BD

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 years-17 years: 500mg po BD

Erythromycin for 5 days¹ (for pregnant patients)

8 years-17 years: 1g po BD

If failed on first line (worsening symptoms on first choice taken for at least 2 to 3 days)

Co-amoxiclav* for 5 days¹

1 month-11 months: co-amoxiclav 125/31/5ml liquid 0.25mL/kg po TDS
1 years-5 years: co-amoxiclav 125/31/5ml liquid 5 mL po TDS
6 years-11 years: co-amoxiclav 250/62/5ml liquid 5 mL po TDS

12 years-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. 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)

Cautions

Aim to use an antibiotic that minimises dosing frequency and is palatable (if suspension prescribed) to optimise adherence.

* These medications can be implicated in C. diff infection. However, this is extremely rare in children. See Foreword if more information is needed.

References

NICE NG91 Otitis media (acute): antimicrobial prescribing, 03/22 LINK accessed 2/23
Antibiotic and diagnostic quick reference tools: Summary of antimicrobial prescribing guidance – managing common infections. RCGP Learning. Accessed at LINK 02/23
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
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. Paediatrics. 2009; 123(2): 424-30. LINK
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.
WHO - Recommendations for management of common childhood 2012 conditions. LINK accessed 2/23
Vilas-Boas AL et al. PNEUMOPAC-Efficacy Study Group. Comparison of oral amoxicillin given thrice or twice daily to children between 2 and 59 months old with non-severe pneumonia: a randomized controlled trial. J Antimicrob Chemother. 2014 Jul;69(7):1954-9.
Fonseca W et al. Comparing pharmacokinetics of amoxicillin given twice or three times per day to children older than 3 months with pneumonia. Antimicrob Agents Chemother. 2003 Mar;47(3):997-1001.
Daschner FD et al. Prospective clinical trial on the efficacy of amoxycillin administered twice or four times daily in children with respiratory tract infections. J Int Med Res. 1981;9(4):274-6.

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

Click here to listen to a podcast on respiratory tract infections in children.

Last updated

Jan 2024

Pneumonia

When to treat¹

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:

Bronchiolitis
Viral induced wheeze
Acute exacerbation of asthma
Croup
Inhaled foreign body
Pertussis
Pneumothorax
Metabolic acidosis e.g. DKA
Heart failure

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:

Significant tachypnoea*
Significant tachycardia*
Severe respiratory distress (significant recession (age younger than12 months), nasal flaring, grunting)
Apnoeas (ages younger than 12 months)
Hypoxia (sustained O₂ sats 92% or less in room air)
Cyanosis
Signs of severe dehydration
Capillary Refill Time longer than 2 seconds

* 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

Consider use of STARWAVe tool² in children presenting with acute RTI and cough for prediction of hospitalisation in the following 30 days:

Characteristics:

· age <2 years

· current asthma

· illness duration of 3 days or less

· parent-reported moderate or severe vomiting in the previous 24 h

· parent-reported severe fever in the previous 24 h or a body temperature of 37·8°C or more at presentation

· clinician-reported intercostal or subcostal recession

· clinician-reported wheeze on auscultation

If 0 or 1 characteristics - 3/1000 risk of hospitalisation in the following 30 days

If 2 or 3 characteristics – 1.5% risk of future hospitalisation in the following 30 days

If 4 or more characteristics – 12% risk of future hospitalisation in the following 30 days: monitor closely and consider if antibiotic treatment is required and/or discussion with local paediatrician.

Safety netting

Provide written and verbal advice:

Treatment choices

First line (if no previous treatment in preceding 4 weeks)

Amoxicillin^3,4, for 5 days³

1 month-11 months: 125mg po TDS^2,6

1 year-4 years: 250mg po TDS^2,6

5 years and over: 500mg po TDS^2,6

Higher doses can be used for severe infections² - see BNFc LINK

Where TDS dosing is impractical: 40mg/kg po BD⁵ (max 1g per dose) could be considered. This is off-label^8,9,10

If no response to amoxicillin OR if considered high risk of complications

If symptoms have not improved after first line therapy, consider sending a sample for example a sputum sample for microbiological testing. The sample should be taken before starting the second line antibiotic.

Co-amoxiclav* for 5 days³

1 month-11 months: 125/31/5ml co-amoxiclav liquid 0.5 mL/kg po TDS

1 year-5 years: co-amoxiclav 125/31/5ml liquid 10 mL po TDS

6 years-11 years: co-amoxiclav 250/62/5ml liquid 10 mL po TDS

12 years-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 (- 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)) OR if no response to first line empirical therapy

Clarithromycin^1,3,4 for 5 days

Weight-based for 1 month to 11 years:

Under 8 kg: 7.5mg/kg po BD

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 years-17 years: 500mg po BD

Erythromycin³ for 5 days (in pregnant patients)

8 years-17 years: 250mg -500mg po QDS

Cautions

Aim to use an antibiotic that minimises dosing frequency and is palatable (if suspension prescribed)to optimise adherence.

* These medications can be implicated in C. diff infection. However, this is extremely rare in children. See Foreword if more information is needed.

References

British Society for Antimicrobial Chemotherapy. Paediatric pathways, pneumonia/empyema. Accessed at LINK 02/23
Hay, A. D., Redmond, N. M., Turnbull, S., Christensen, H., Thornton, H.,Little, P., Thompson, M., Delaney, B., Lovering, A. M., Muir, P., Leeming, J. P., Vipond, B., Stuart, B., Peters, T. J., & Blair, P. S. (2016). Development and internal validation of a clinical rule to improve antibiotic use in children presenting to primary care with acute respiratory tract infection and cough: a prognostic cohort study. The Lancet. Respiratory medicine, 4(11), 902–910.
NICE. Pneumonia (community-acquired): antimicrobial prescribing [NG138]. September 2019. Accessed at LINK 02/23
Antibiotic and diagnostic quick reference tools: Summary of antimicrobial prescribing guidance – managing common infections. RCGP Learning. Accessed at LINK 02/23
Bielicki J.A. et al. Effect of Amoxicillin Dose and Treatment Duration on the Need for Antibiotic Re-treatment in Children With Community-Acquired Pneumonia. The CAP-IT Randomized Clinical Trial. JAMA.2021;326(17):1713-1724.
WHO - Recommendations for management of common childhood 2012 conditions. LINK accessed 02/23
BNFc accessed at LINK 02/23
Fonseca W et al. Comparing pharmacokinetics of amoxicillin given twice or three times per day to children older than 3 months with pneumonia. Antimicrob Agents Chemother. 2003 Mar;47(3):997-1001.
Vilas-Boas AL et al. PNEUMOPAC-Efficacy Study Group. Comparison of oral amoxicillin given thrice or twice daily to children between 2 and 59 months old with non-severe pneumonia: a randomized controlled trial. J Antimicrob Chemother. 2014 Jul;69(7):1954-9.
Daschner FD et al. Prospective clinical trial on the efficacy of amoxycillin administered twice or four times daily in children with respiratory tract infections. J Int Med Res. 1981;9(4):274-6.

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

Click here to listen to a podcast on respiratory tract infections in children.

Last updated

Jan 2024

Rhinosinusitis

When to treat

Generally antibiotics are not required. Majority of cases resolve in 14-21 days without them (regardless of cause; bacterial or viral)
Advise adequate analgesia
Consider treating with antibiotic if most of the following are present:¹
- Symptoms for more than 10 days
- Marked deterioration after an initial milder phase
- Fever
- Unremitting purulent nasal discharge
- Severe localised unilateral pain (particularly pain over teeth and jaw)

Sinusitis can be associated with CNS complications. This is rare in children under 8 years old.

RED FLAGS raising possibility of CNS complications include:

Severe headache persisting despite regular analgesia (ibuprofen and paracetamol) or worse on lying down / in morning
Severe retroorbital pain
Persistent vomiting
New onset squint or diplopia - covering up one eye
Deteriorating vision - complaining of blurred vision
New limb weakness – may exhibit change of hand preference
Unsteady gait or coordination issues
Increasing drowsiness
Meningism / irritability

If a child has these symptoms, consider urgent referral to secondary care (paediatrics)

Treatment choices

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).

For children aged 5 years and over, consider prescribing tablets/capsules and signposting to pill swallowing information on the Healthier Together website or Medicines for Children website. If the child is unable to swallow the tablets/capsules see the advice from Specialist Pharmacy Service (SPS) about using solid oral dosage form antibiotics in children (https://www.sps.nhs.uk/articles/using-solid-oral-dosage-form-antibiotics-in-children/).

First line antibiotics

Phenoxymethylpenicillin (Penicillin V) 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.

1 month-11 months: 62.5mg po QDS^1,2
1 year-5 years: 125mg po QDS^1,2
6 years-11 years: 250mg po QDS^1,2
12 years-17 years: 500mg po QDS^1.2

OR alternative is:

Amoxicillin for 5 days - if no previous antibiotic treatment in preceding 4 weeks

By age
1 month-11 months: 125mg po TDS²
1 year-4 years: 250mg po TDS²
5 years and over: 500mg po TDS²

Where TDS dosing is impractical: 40mg/kg po BD⁶ (max 1g per dose) could be considered. This is off-label^3,4,5

If treatment with amoxicillin in preceding 4 weeks or consider high risk of complications

Co-amoxiclav* for 5 days^1,2

1 month-11 months: co-amoxiclav 125/31/5ml liquid 0.25mL/kg po TDS
1 year-5 years: co-amoxiclav 125/31/5ml liquid 5 mL po TDS
6 years-11 years: co-amoxiclav 250/62/5ml liquid 5 mL po TDS
12 years-17 years: co-amoxiclav tablets (500/125 mg) 1 po TDS or co-amoxiclav (250/62/5ml) liquid 10 mL po TDS

Clarithromycin for 5 days¹

Weight based for 1 month to 11 years:

Under 8 kg: 7.5mg/kg po BD

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 years-17 years: 500mg po BD

Doxycycline¹ for total of 5 days

12 years-17 years: 200mg po on first day, then 100mg OD for 4 days

Safety netting

Provide verbal and written advice

Cautions

Aim to use an antibiotic that minimises dosing frequencyand is palatable (if suspension prescribed) to optimise adherence. The unpleasant taste and palatability of Phenoxymethylpenicillin (Penicillin V) suspension can affect adherence to antibiotics, which may result in treatment failure.

* These medications can be implicated in C. diff infection. However, this is extremely rare in children. See Foreword if more information is needed.

References

NICE guideline NG79 (2017) Sinusitis (acute): antimicrobial prescribing. Accessed at LINK 02/23
BNFc accessed at LINK 02/23
Vilas-Boas AL et al. PNEUMOPAC-Efficacy Study Group. Comparison of oral amoxicillin given thrice or twice daily to children between 2 and 59 months old with non-severe pneumonia: a randomized controlled trial. J Antimicrob Chemother. 2014 Jul;69(7):1954-9.
Fonseca W et al. Comparing pharmacokinetics of amoxicillin given twice or three times per day to children older than 3 months with pneumonia. Antimicrob Agents Chemother. 2003 Mar;47(3):997-1001.
Daschner FD et al. Prospective clinical trial on the efficacy of amoxycillin administered twice or four times daily in children with respiratory tract infections. J Int Med Res. 1981;9(4):274-6.
WHO - Recommendations for management of common childhood 2012 conditions. LINK accessed 02/23
Malhotra-Kumar Set 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.

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

Click here to listen to a podcast on respiratory tract infections in children.

Last updated

Jan 2024

Scabies

Current supply issue with Permethrin 5% cream

The Department of Health and Social Care (DHSC) has issued a medicine supply notification for Permethrin 5% w/w cream - see below.

Permethrin 5% w/w cream is in limited supply until further notice due to an increase in demand.
Unlicensed supplies of permethrin 5% cream may be sourced, lead times vary.
Malathion liquid, an alternative to permethrin for treatment of scabies, is currently unavailable.
Crotamiton 10% Cream (Eurax), which is licensed for the treatment of scabies, remains available but can only meet its current demand for other conditions.
Benzyl benzoate 25% topical emulsion can be sourced from special-order manufacturers; this is an unlicensed medicine.
Ivermectin 3mg tablets are licensed for treatment of scabies but are not currently marketed in the UK. Unlicensed supplies of ivermectin 3mg tablets may be sourced, lead times vary Ivermectin dosing information

For further information, please see MSN issued on 08/09/23 or the link to SPS

When to treat¹

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.

Treatment choices

First line

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 permethrin 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

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 recurrence occurs where all contacts were treated simultaneously and treatment was applied correctly, give a course of a different insecticide.¹

General advice

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

References

NICE CKS Scabies LINK revised 11/17 accessed 07/21
BNFc accessed at LINK in 11/21

Click here for a link to South Central Antimicrobial Network (SCAN) Guidelines for Antibiotic Prescribing in the Community.

Last updated

Jan 2024

Threadworm

When to treat¹

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

NOTE: 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 years^1,2,3

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-infection²Continue 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) bedsheets daily for several days after treatment; 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

References

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.

Click here for a link to South Central Antimicrobial Network (SCAN) Guidelines for Antibiotic Prescribing in the Community.

Last updated

Jan 2024

Tonsillitis

When to treat

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

Base decision about antibiotic treatment on FeverPAIN^1,2 score (1 point for each of fever, purulence, attend within 3 days of onset or less, severely Inflamed tonsils, no cough or coryza):

Score 0-1: 13-18% likelihood of isolating streptococcus: use NO antibiotics
Score 2-3: 34-40% likelihood of isolating streptococcus: use back up/delayed antibiotic OR NO antibiotic
Score 4 or more: 62-65% likelihood of isolating streptococcus: use immediate antibiotic OR back-up antibiotic

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

When to investigate

Most children with tonsillitis do not require a throat swab.

For UK HSA guidance on the role of point of care streptococcal tests, click here.

Safety netting

Provide verbal and written advice

Treatment choices

For children unable to swallow tablets:

Note: for children aged 5 years and over, consider prescribing tablets/capsules and signposting to pill swallowing resources pill swallowing information on the Healthier Together website or Medicines for Children website. If the child is unable to swallow the tablets/capsules see the advice from Specialist Pharmacy Service (SPS) about using solid oral dosage form antibiotics in children.

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.

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

OR alternative is:

Amoxicillin for 5 days

By age:

1 month-11 months: 125mg po TDS³

1 year-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-label^8,9,10

For children able to swallow tablets

Phenoxymethylpenicillin (Penicillin V)¹ for 5 days

6 years-11 years: 500 mg po BD

12 years or over: 1g po BD

Clarithromycin¹ for 5 days

Weight-based for 1 month to 11 years:

Under 8 kg: 7.5mg/kg po BD

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 years-17 years: 250mg-500mg po BD

In pregnancy: Erythromycin¹ for 5 days

8 years-17 years: 500mg-1g po BD

Cautions

Aim to use an antibiotic that minimises dosing frequency and is palatable (if suspension prescribed)to optimise adherence. The unpleasant taste and palatability of Phenoxymethylpenicillin (Penicillin V) suspension can affect adherence to antibiotics, which may result in treatment failure.
Although there has been great anxiety about prescribing amoxicillin in patients with tonsillitis due to the risk of adverse events associated with EBV, there is emerging data to suggest that the use of amoxicillin does not significantly increase the risk of rash in acute EBV – see LINK. In addition, data suggests that EBV accounts for as little as 1% of tonsillitis presenting to doctors - see LINK and more importantly, EBV is extremely rare in children below 12 years of age. For this reason, the current recommendation is to use amoxicillin suspension in young children (palatability) and phenoxymethylpenicillin (penicillin V) tablets for children able to swallow tablets (due to higher rates of EBV in this age group).

References

NICE NG84, Sore throat (acute): antimicrobial prescribing. 01/18 LINK date accessed 02/23
Antibiotic and diagnostic quick reference tools: Summary of antimicrobial prescribing guidance – managing common infections. RCGP Learning. Accessed at LINK 02/23
BNFc accessed at LINK 02/23
WHO - Recommendations for management of common childhood 2012 conditions. LINK accessed 02/23
Spinks A et al. Antibiotics for sore throat. Cochrane Database Syst Rev. 2013; (11): CD000023. LINK
Little P et al. Open randomised trial of prescribing strategies in managing sore throat. BMJ. 1997; 314(7082): 722-7. LINK
Little P et al. Predictors of suppurative complications for acute sore throat in primary care: prospective clinical cohort study. BMJ. 2013; 347: f6867 LINK
Fonseca W et al. Comparing pharmacokinetics of amoxicillin given twice or three times per day to children older than 3 months with pneumonia. Antimicrob Agents Chemother. 2003 Mar;47(3):997-1001.
Vilas-Boas AL et al. PNEUMOPAC-Efficacy Study Group. Comparison of oral amoxicillin given thrice or twice daily to children between 2 and 59 months old with non-severe pneumonia: a randomized controlled trial. J Antimicrob Chemother. 2014 Jul;69(7):1954-9.
Daschner FD et al. Prospective clinical trial on the efficacy of amoxycillin administered twice or four times daily in children with respiratory tract infections. J Int Med Res. 1981;9(4):274-6.

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

Click here to listen to a podcast on respiratory tract infections in children.

Last updated

Jan 2024

Urinary Tract Infection

When to treat

Child under 3 months with temp 38°C or greater, or age 3 months or older and haemodynamically unstable: refer URGENTLY to secondary care for assessment.
Consider UTI in any sick child and every young child with unexplained fever. Consider differential diagnoses: sepsis, meningitis, GI obstruction, appendicitis, gastroenteritis. Other differentials for dysuria/discomfort include vulvovaginitis and threadworms.
UTIs in children require prompt treatment to minimise the risk of renal scarring.
If UTI suspected but systemically well and apyrexial, suggestive of lower UTI.
If upper UTI suspected (fever with or without symptoms of pyelonephritis), and urine nitrites and/or leukocytes positive, send urine for culture and start empirical treatment. Provide family with UTI safety netting information.
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)
Imaging: only refer if child under 6 months, recurrent or atypical UTI.

When to investigate

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.

Safety netting

Provide written and verbal advice

Treatment choices

Under 3 months old

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.

3 months and over

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

Nitrofurantoin^1,2 (Only if child can swallow tablets, previous treatment with trimethoprim in preceding 3 months and eGFR 45ml/min/1.73m² and over):

12-17 years: 100mg MR po BD¹

See 26/4/23 Nitrofurantoin: reminder of the risks of pulmonary and hepatic adverse drug reactions

Cefalexin*

3 months up to 12 years: 12.5mg/kg (max 1g per dose) po BD¹

Or by age:

3-11 months: 125mg po BD¹

1-4 years: 125mg po TDS¹

5-11 years: 250mg po TDS¹

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 (max 750mg po BD)³

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*

3 months up to 12 years: 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:

Ciprofloxacin* 10mg/kg po BD (double dose in severe infection) (max 750mg po BD)³

Preventing recurrence

Address dysfunctional elimination syndromes and constipation
Encourage children to drink an adequate amount
Emphasize the importance of not delaying voiding. Children should have ready access to clean toilets

Cautions

Aim to use an antibiotic that minimises dosing frequency and is palatable (if suspension prescribed)to optimise adherence.
Risk factors for recurrent UTIs:
- Constipation
- Poor fluid intake
- Infrequent voiding especially at school (holding on)
- Irritable bladder (can happen following UTI)
- Neuropathic bladder
  - Examine spine
- Genitourinary abnormalities
  - Examine genitalia

* These medications can be implicated in C. diff infection. However, this is extremely rare in children. See Foreword if more information is needed.

Evidence

This guideline cites a range of studies that suggest that all infants and children who have bacteriuria and either fever of 38°C or higher, or loin pain/tenderness, should be considered to have acute pyelonephritis/upper urinary tract infection. All other infants and children who have bacteriuria, but no systemic symptoms or signs, should be considered to have cystitis/lower urinary tract infection. Findings indicated that shorter courses of antibiotics (7 to 10 days) improved compliance, decreased antibiotic-related adverse events, and diminished the emergence of resistant organisms. Antibiotics with low local resistance patterns have therefore been chosen.
Nitrofurantoin should be avoided in patients with an estimated glomerular filtration rate (eGFR) of less than 45ml/min but may be used with caution in certain patients if potential benefit outweighs risk with an eGFR of 30 to 44 ml/min/1.73m² if a short course (max 7 days) is prescribed.^3,5

References

NICE (2018). Urinary tract infection (lower):antimicrobial prescribing 2018 LINK accessed 02/23
Antibiotic and diagnostic quick reference tools: Summary of antimicrobial prescribing guidance – managing common infections. RCGP Learning. Accessed at LINK 12/21
BNFc accessed at LINK in 12/21
NICE NG111 Pyelonephritis (Acute):antimicrobial prescribing 10/18 LINK
MHRA 2015. Accessed 12/21 LINK
PHE. Diagnosis of urinary tract infections. Quick reference tool for primary care for consultation and local adaptation. April 2019. Accessed at LINK August 2019
Strohmeier Y et al. Antibiotics for acute pyelonephritis in children. Cochrane Database Syst Rev. 2014; 7
Michael M et al. Short versus standard duration oral antibiotic therapy for acute urinary tract infection in children. Cochrane Database Syst Rev. 2003;(1):CD003966.

RECURRENT UTIs (children 3 months of age and older)

Recurrent UTIs occur not infrequently in children and can be extremely distressing. They occur most commonly in girls aged from about 5 years to early teen years. It is important to confirm that the child is having recurrent UTIs by sending appropriately collected urine samples for culture.

Definition of recurrent UTI:

· Two or more episodes of UTI with acute pyelonephritis/upper urinary tract infection, or

· One episode of UTI with acute pyelonephritis/upper urinary tract infection plus one or more episode of UTI with cystitis/lower urinary tract infection, or

· Three or more episodes of UTI with cystitis/lower urinary tract infection.

Preventing recurrent UTIs:

Parents can play a crucial role in reducing the frequency of these infections by encouraging the following practices:

Wiping Front to Back:
- Encourage wiping from front to back after toileting. This helps prevent the transfer of bacteria from the bottom to the bladder.
Avoiding Bubble Bath and Shampoo:
- Refrain from using bubble bath and shampoo in bathwater, as these products may compromise the protective mucus around the urethra. Ideally encourage children to have showers rather than baths
Encourage children to "Drink Lots and Wee Often":
- Encourage the child to stay well-hydrated and to empty their bladder regularly. Some children may resist using school toilets, and addressing this is important to prevent holding onto urine for extended periods.
Addressing constipation:
- Incomplete bladder emptying is often linked to constipation in children. Proper treatment and control of constipation are essential in reducing the risk of recurrent UTIs. For information that you can share with parents, click here. For clinical pathway on the management of constipation in children, click here.

Management of recurrent UTIs:

If the child continues to experience recurrent UTIs despite the prevention measures listed above, arrange paediatric review. The following may be considered whilst waiting for secondary care review:

Post-void ultrasound to confirm complete bladder emptying
Prophylactic antibiotics
- Choose antibiotics according to recent culture and susceptibility results where possible
- Ab prophylaxis may need to be continued until the child remains infection-free for six months.
- 1^st line = trimethoprim

· 3 to 5 months, 2 mg/kg at night (maximum 100 mg per dose) or 12.5 mg at night

· 6 months to 5 years, 2 mg/kg at night (maximum 100 mg per dose) or 25 mg at night

· 6 to 11 years, 2 mg/kg at night (maximum 100 mg per dose) or 50 mg at night

· 12 to 15 years, 100 mg at night