Guidance for initial antibiotic therapy in children in acute hospitals. Specialist units may have separate policies.

Infection Management Guidelines: Empirical Antibiotic Therapy for Children

STOP AND THINK BEFORE YOU GIVE ANTIBIOTIC THERAPY! The initial treatment may need to be modified according to clinical response and results of microbiology and other investigations. The appropriate specimens of microbiology should be taken whenever possible before administering antibiotics; however this will depend upon the severity of the illness and the nature of the specimen. In patients who are stable and not septic, and in whom infection is only one of a number of possibilities, consideration should be given to deferring antibiotics until the results of cultures are known, as long as there is no change in the clinical condition in the interim. Upper Respiratory Tract Lower Respiratory Tract Skin/Soft Tissue Urinary Tract Gastrointestinal Bone/Joint Infection CNS Sepsis or Feverish Illness Unknown Source Neonates - community acquired Benzylpenicillin IV + Gentamicin ** IV. In Penicillin allergy, Cefotaxime IV + Gentamicin ** IV. Neonates nosocomial Gentamicin ** IV + Vancomycin ** IV. 1 3 months Cefotaxime IV + Amoxicillin IV. > 3 months Cefotaxime IV. After 48 hours, if child is > 3 months and unlikely to require HDU/ITU care then consider switching to Ceftriaxone* IV. If known MRSA carrier or in penicillin allergy give: > 1 month Vancomycin ** IV + Gentamicin ** IV +/- Metronidazole IV. Neutropenic Sepsis Piperacillin/tazobactam IV + Gentamicin ** IV. In mild Penicillin allergy: Ceftazidime IV + Gentamicin ** IV. Add Teicoplanin IV if fever and/or rigors after line flushed earlier in day or soon after new line inserted. Endocarditis

Tonsillitis Benzylpenicillin IV (if unable to swallow) Switch to oral Penicillin V. In Penicillin allergy, Clarithromycin IV (if unable to swallow) Switch to oral Clarithromycin. Duration: 10 days.

Pneumonia Young children (< 2 years) with mild symptoms do not need antibiotics.

Limited soft tissue infection Flucloxacillin oral + Penicillin V oral. In Penicillin allergy, Neonates Erythromycin oral. > 1 month Clarithromycin oral.

Non-severe community acquired pneumonia (CAP) Amoxicillin (IV or oral) or if true Penicillin allergy or atypical suspected Clarithromycin (IV or oral). Duration 3 - 5 days (10 days if atypical). Severe CAP Neonates Benzylpenicillin IV + Gentamicin IV > 1 month Co-amoxiclav IV If atypical pneumonia suspected + Clarithromycin IV/oral. Switch to oral Co-amoxiclav +/- Clarithromycin. If Penicillin allergy, > 1 month Cefuroxime IV +/- Clarithromycin oral. Switch to oral Cefpodoxime +/- Clarithromycin. Duration: 7 - 10 days. Aspiration Pneumonia Co-amoxiclav IV. Switch to oral Co-amoxiclav. If Penicillin allergy, Cefuroxime IV + Metronidazole IV. Switch to oral Cefpodoxime + Metronidazole. Duration: 7 days.

Acute Otitis Media Avoid or delay antibiotics in children without systemic features. Amoxicillin oral If severe, Co-amoxiclav IV. In Penicillin allergy, Clarithromycin oral. If severe, Cefuroxime IV. Duration: 5 days.

Moderate to severe Cellulitis Flucloxacillin IV + Benzylpenicillin IV. Switch to oral Flucloxacillin +/- Penicillin V. In Penicillin allergy, Vancomycin ** IV. Switch to oral erythromycin for neonates or clarithromycin if > 1 month. Duration: 7 - 14 days. Orbital Cellulitis Seek ENT/Ophthalmology advice. Co-amoxiclav IV then oral. Duration: 7 10 days. Animal bite Co-amoxiclav oral. In Penicillin allergy, > 6 months and < 12 years Co-trimoxazole oral + Metronidazole oral. > 12 years Doxycycline oral + Metronidazole oral. Duration: 5 days. Human Bite Co-amoxiclav oral. In penicillin allergy, Clarithromycin oral. + (if severe) Metronidazole oral. Duration: 7 days.

Lower UTI/cystitis If child is receiving prophylactic medication and develops an infection, treatment should be with a different antibiotic. > 1month - 12 years Trimethoprim oral 4mg/kg (max 200mg) twice daily. 12 - 18 years Trimethoprim oral 200mg twice daily. Or > 1month - 12 years Cefalexin oral 12.5mg/kg twice daily (max 1g 4 times daily). 12 - 18 years Cefalexin oral 500mg 2 or 3 times daily. Duration: 3 days. Prophylaxis of recurrent symptomatic UTIs > 1 month - 12 years Trimethoprim 2mg/kg (max 100mg) at night. 12 - 18 years Trimethoprim 50 - 100mg at night. Or > 1 month - 18 years Cefalexin 12.5mg/kg (max 125mg) at night. Review once investigations completed.

Gastroenteritis No antibiotic usually required.

Acute Osteomyelitis/Septic arthritis/Acute discitis/ Deep muscle sepsis If < 2 years and no sensitivities: Flucloxacillin IV + Cefuroxime IV. If > 2 years or if Staphylococcus aureus confirmed: Flucloxacillin IV + Sodium Fusidate oral. IV therapy is usually required for 14 days but a switch to oral therapy can be considered once the patient is apyrexial for 48 hours. In Penicillin allergy or MRSA likely, Vancomycin ** IV. If < 2 years Add Gentamicin ** IV. If pseudomonas likely use Ceftazidime IV. Duration: 4 - 6 weeks, guided by inflammatory markers and clinical response.

IV therapy to be administered URGENTLY on arrival at hospital and after blood cultures. Always refer to senior staff. Seek ID/microbiology advice. Meningitis or Meningococcal Septicaemia < 3 months Cefotaxime IV + Amoxicillin IV. > 3 months Cefotaxime IV. Add Vancomycin ** IV if recently overseas, or prolonged multiple antibiotic exposure within last 3 months. After 48 hours if child is > 3 months and unlikely to require HDU/ITU care then consider switching to Ceftriaxone * IV. Refer to BNFC for course lengths for appropriate organisms.

Possible infective endocarditis Consult a cardiologist immediately. Acute: Flucloxacillin IV + Gentamicin ** V. Indolent: Benzylpenicillin IV (or Amoxicillin IV) + Gentamicin ** IV. or if true Penicillin allergy/ intra-cardiac prosthesis/ suspected MRSA: Vancomycin ** IV + Rifampicin oral + Gentamicin ** IV.

Appendicitis/Peritonitis/ Penetrating abdominal trauma < 3 months Cefotaxime IV + Metronidazole IV. > 3 months Ceftriaxone * IV + Metronidazole IV. If not responding, change to Amoxicillin IV + Metronidazole IV + Gentamicin ** IV. Switch to oral Co-amoxiclav. If beta-lactam allergy, Clindamycin IV then oral. Duration: 3 - 7 days.

* Ceftriaxone - refer to BNFC for contraindications. ** Gentamicin / Vancomycin - see IV monograph. The IV route for Clarithromycin is not licensed in children.

Pyelonephritis < 6 months Cefotaxime or Ceftriaxone* IV. > 6 months Co-amoxiclav IV. Add Gentamicin ** IV if severe infection or unresponsive after 48 hours. Switch to oral trimethoprim if sensitive. Duration: 7 - 10 days. Severe Penicillin allergy > 1 month Ciprofloxacin IV/ oral for 7 days.

FURTHER ADVICE can be obtained from the Consultant Paediatrician, Duty Microbiologist or Clinical Pharmacist or the ID Unit Aberdeen Royal Infirmary. Infection Control advice may be given by the duty microbiologist. The full antibiotic guidelines and policies can be found on the intranet at www.nhsgrampian.org/gjf - Chapter 5 Infections. Produced by the NHS Grampian Antimicrobial Management Team October 2011. Review October 2012.

Catheter-related UTI Remove/replace catheter and culture urine. Antibiotics are not indicated unless the patient has evidence of systemic infection eg pyrexia, loin pain, raised WCC or acute confusion. If systemic infection likely treat as for pyelonephritis. Prophylaxis of UTI and bacteraemia Patients with clinical evidence of a UTI should be treated with appropriate antibiotics before or at the time of catheter insertion. Antibiotic prophylaxis at catheter insertion is only indicated in patients for whom bacteriuria is associated with a high risk of sepsis or those at particular risk of infective endocarditis. See full guidance for high risk conditions and treatment options.

REVIEW ANTIBIOTIC THERAPY DAILY STOP? SIMPLIFY? SWITCH?

RATIONALISE ANTIBIOTIC THERAPY when microbiology results become available or clinical condition changes. Review IV therapy daily and remember IV - ORAL SWITCH - see IVOST policy on intranet