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Trust Antibiotic Policy for the Empirical Management of Common Infections in Paediatrics

A Clinical Guideline recommended for use

In: Paediatrics

By: Medical and Nursing Staff


Empirical first-line antimicrobial therapy of Children and Young
For:
People (1 month 16 years) with infection
Key words: Antibiotic, Infection
Dr Caroline Kavanagh, Consultant Paediatrician
Caroline Hallam, Specialist Pharmacist, Antimicrobials
Written by: Dr Nandu Thalange, Consultant Paediatrician
Dr Catherine Tremlett, Consultant Microbiologist
Dr Bron Hennebry , ST3 Paediatric Trainee
Mr Kulkarni, Clinical Director, Paediatrics
Jenny Lind Childrens Department
Supported by:
Microbiology Department
Pharmacy Department

Approved by Chairs action 30 March 2015 and reported


Approved by: to Clinical Guidelines Assessment Panel
(CGAP) on 15 April 2015

Reported as approved Clinical Standards Group


to the:
Effectiveness Sub-Board

Date of approval March 2015

To be reviewed before: March 2018


Dr Caroline Kavanagh, Caroline Hallam, Dr Nandu Thalange,
To be reviewed by:
Dr Catherine Tremlett
Guideline supersedes: CA5084

Guideline Reg. No: CA5084 v2.1

This guideline has been approved by the Trust's Clinical Guidelines Assessment Panel as an aid to the diagnosis and
management of relevant patients and clinical circumstances. Not every patient or situation fits neatly into a standard guideline
scenario and the guideline must be interpreted and applied in practice in the light of prevailing clinical circumstances, the
diagnostic and treatment options available and the professional judgement, knowledge and expertise of relevant clinicians. It is
advised that the rationale for any departure from relevant guidance should be documented in the patient's case notes.

The Trust's guidelines are made publicly available as part of the collective endeavour to continuously improve the quality of
healthcare through sharing medical experience and knowledge. The Trust accepts no responsibility for any misunderstanding
or misapplication of this document.

Author/s: Dr Caroline Kavanagh, Caroline Hallam, Dr Nandu Thalange, Dr Catherine Tremlett, Dr Bron Hennebry Date of issue: March 2015
Valid until: March 2018 Guideline Ref No (CA5084) v 2.1
Document: Trust Antibiotic Policy for the Management of Common Infections in Paediatrics
Copy of complete document available from: Trust Intranet Page 1 of 16
Trust Antibiotic Policy for the Empirical Management of Common Infections in
Paediatrics

Page
Contents

Introduction 3

Genito-Urinary Infections 5-6

Bone and Joint Infections 6

Soft Tissue Infections 6- 7

Respiratory Infection 7-9

ENT Infections 9

Central Nervous System Infections 10

Gastro-Intestinal/Abdominal Infections 11-12

Endocarditis 13

Bacteraemia & Septicaemia 14

Eye Infections 15

Author/s: Dr Caroline Kavanagh, Caroline Hallam, Dr Nandu Thalange, Dr Catherine Tremlett, Dr Bron Hennebry Date of issue: March 2015
Valid until: March 2018 Guideline Ref No (CA5084) v 2.1
Document: Trust Antibiotic Policy for the Management of Common Infections in Paediatrics
Copy of complete document available from: Trust Intranet Page 2 of 16
Trust Antibiotic Policy for the Empirical Management of Common Infections in
Paediatrics

Introduction:
The objective of this guideline is to ensure the appropriate selection of antimicrobials for the
empirical treatment of common infections in children (age 1 month to 16 years).

History of recent infections and organisms isolated should be considered when deciding
which antibiotic to use.
Only use antibiotics when infection has been recognised or when there is a high degree of
suspicion of infection.
Remember to take appropriate diagnostic samples before starting antibiotics whenever
possible
The indication for prescribing should be written below the antibiotic on the DRUG
CHART for all prescriptions.
Keep all courses of antibiotics as short as possible. Five days treatment is sufficient for many
infections.
Specify a stop date for the antibiotic if possible, if not specify a review date.
Change from the IV to oral route as soon as is possible (see IV to oral conversion guidelines
CA 1091)
Review antibiotics on a DAILY BASIS
Notifiable infections/diseases are indicated with a red flag
Some Drugs for uncommon indications may not be approved for use in the hospital.
Named patient approval must be sought from the Chair of the Drug, Therapeutics &
Medicines Management (DTMM) Committee.

Antibiotic choices are listed in preference of recommended use.

Dose: Consult the BNF for children for the correct dose.

Length of Treatment: The ongoing parenteral administration of an antibiotic should be


regularly reviewed with a consideration of switching therapy to the oral route. The duration
of therapy depends on the nature of the infection and the response to treatment. Courses
should not be unduly prolonged because they encourage resistance, they may lead to side
effects and they are costly, although in certain infections a prolonged course is
unavoidable. A suggested length of treatment is specified as a guide and treatment should
be regularly reviewed in light of clinical circumstances and microbiology recommendation.

Prescribing in Penicillin allergy:


.
Patients with a history of rash occurring more than 72 hours after administration of
penicillins are probably not allergic to penicillins, (SIGN, 2000) and many patients
with a history of rash after penicillins will have received cephalosporins with no ill
effect. For patients who do NOT report an anaphylactic or urticarial response to
penicillin a cephalosporin or carbapenem (e.g. meropenem) may be administered
with caution.

Author/s: Dr Caroline Kavanagh, Caroline Hallam, Dr Nandu Thalange, Dr Catherine Tremlett, Dr Bron Hennebry Date of issue: March 2015
Valid until: March 2018 Guideline Ref No (CA5084) v 2.1
Document: Trust Antibiotic Policy for the Management of Common Infections in Paediatrics
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Trust Antibiotic Policy for the Empirical Management of Common Infections in
Paediatrics

Patients with a history of anaphylaxis or urticaria occurring immediately after


penicillin therapy are at increased risk of immediate hypersensitivity to penicillins
and should not receive treatment with a beta- lactam antibiotic (this includes
cephalosporins) or carbapenem, unless they have previously received a beta-
lactam and had no adverse effects

Please note that penicillins include amoxicillin, co-amoxiclav (Augmentin),


flucloxacillin, Tazocin.

Gentamicin and Vancomycin:


Gentamicin is potentially TOXIC if not used appropriately. Refer to guideline Trust
Management for the Use of Once Daily Gentamicin in Children.

Vancomycin For information on vancomycin prescribing and monitoring consult the BNF
for Children.

EXTREME CAUTION SHOULD BE USED WHEN TREATING WITH GENTAMICIN AND


VANCOMYCIN TOGETHER. This combination is indicated by a warning triangle .

Author/s: Dr Caroline Kavanagh, Caroline Hallam, Dr Nandu Thalange, Dr Catherine Tremlett, Dr Bron Hennebry Date of issue: March 2015
Valid until: March 2018 Guideline Ref No (CA5084) v 2.1
Document: Trust Antibiotic Policy for the Management of Common Infections in Paediatrics
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Trust Antibiotic Policy for the Empirical Management of Common Infections in Paediatrics
Genito-Urinary Infection
Common Penicillin Allergy
Infection First Line Notes
Organisms (Also See guidance notes)
Co-Amoxiclav PO Cefradine capsules/Cefalexin elixir PO
OR OR See also NICE Clinical Guideline 54.
Cefradine capsules/Cefalexin elixir PO Nitrofurantoin PO
Uncomplicated UTI Gram negative Bacilli
3 days 3 days oral therapy recommended.
PO Review if still unwell at 24-48 hours.
If history of penicillin anaphylaxis
3 days Nitrofurantoin PO 3 days
Co-Amoxiclav PO/IV Cefotaxime IV Gentamicin IV Consider switching to oral antibiotics at 48-96
OR If history of penicillin anaphylaxis hours if not commenced on oral therapy.
Gram negative Bacilli Cefotaxime IV Gentamicin IV NICE defines Atypical UTI as:
Ciprofloxacin IV/PO
Seriously ill
7-10 days 7-10 days Poor urine flow
Atypical UTI including
Abdominal or bladder mass
Pyelonephritis Ciprofloxacin PO (IV if not absorbing) Cefotaxime IV Gentamicin IV
Raised creatinine
OR If history of penicillin anaphylaxis Septicaemia
Pseudomonas Ceftazidime IV Gentamicin IV Ciprofloxacin IV/PO Failure to respond to treatment with
7-10 days 7-10 days suitable antibiotics within 48 hours
Infection with non-E. coli organisms
Nitrofurantoin PO
Nitrofurantoin PO UTI prophylaxis not recommended. If used,
OR
OR be guided by culture sensitivities.
Trimethoprim PO
UTI prophylaxis Gram negative Bacilli Cefalexin elixir PO
OR
OR High rates of resistance to amoxicillin and
Cefalexin elixir PO (if no history of trimethoprim locally.
Trimethoprim PO
penicillin anaphylaxis)
Doxycycline (>12y) Doxycycline (>12y)
OR OR
Syphilis Treponema pallidum Erythromycin Erythromycin Consider Safeguarding issues.
Early infection 14 days Early infection 14 days
Late/latent infection 28 days Late/latent infection 28 days
Ceftriaxone IV/IM <12y
Ceftriaxone IV/IM <12y OR
OR Ciprofloxacin PO
Gonorrhoea Neisseria gonorrhoeae Ciprofloxacin PO Consider Safeguarding issues.
If history of penicillin anaphylaxis
Single dose Ciprofloxacin PO
Single dose

Chlamydia trachomatis
Chlamydia/ Erythromycin PO <12y for 12 days Erythromycin PO <12y for 12 days
Non-Gonococcal Ureaplasma urealyticum, OR OR Consider Safeguarding issues.
Haemophilus vaginalis, Doxycycline PO >12y for 7 days Doxycycline PO >12y for 7 days
Urethritis Mycoplasma genitalium

Author/s: Dr Caroline Kavanagh, Caroline Hallam, Dr Nandu Thalange, Dr Catherine Tremlett, Dr Bron Hennebry Date of issue: March 2015
Valid until: March 2018 Guideline Ref No (CA5084) v 2.1
Document: Trust Antibiotic Policy for the Management of Common Infections in Paediatrics
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Trust Antibiotic Policy for the Empirical Management of Common Infections in Paediatrics

Genito-Urinary Infection Continued


Common Penicillin Allergy
Infection First Line Notes
Organisms (Also See guidance notes)
Chlamydia trachomatis
Ureaplasma urealyticum, Doxycycline PO >12y + Doxycycline PO >12y +
Pelvic Inflammatory Neisseria gonorrhoeae, Metronidazole + Metronidazole +
Disease Gardnerella vaginalis, Ceftriaxone IM (single dose) Ceftriaxone IM (single dose) Consider Safeguarding issues.
Haemophilus influenzae,
Peptococcus spp 14 days 14 days
Bacteroides spp

Bone and Joint Infections


Common Penicillin Allergy
Infection First Line Notes
Organisms (Also See guidance notes)
Discuss management and therapy duration
Staphylococcus aureus Ceftriaxone IV Ceftriaxone IV with Microbiology, Paediatric Rheumatologist
and Orthopaedic surgeons.
Osteomyelitis or Group A Streptococcus OR
Co-Amoxiclav IV
If history of penicillin anaphylaxis
Use vancomycin If known or suspected MRSA.
Septic arthritis Streptococcus pneumoniae Vancomycin IV + Gentamicin
Haemophilus influenzae B invasive Group A streptococcal disease
is a Notifiable Disease.

Soft Tissue Infections


Common Penicillin Allergy
Infection First Line Notes
Organisms (Also See guidance notes)
Flucloxacillin IV/PO Clarithromycin IV/PO IV therapy indicated in moderate to severe
OR OR cellulitis. Change to oral when clinically
Cellulitis, Impetigo, Staphylococcus aureus Co-Amoxiclav IV/PO Clindamycin IV/PO appropriate.
erysipelas Group A Streptococcus 7 days 7 days
If Immunocompromised If Immunocompromised invasive Group A streptococcal disease
Clindamycin IV +Ceftazidime IV 7 days Clindamycin IV +Ceftazidime IV 7 days is a Notifiable Disease.
Treat affected person and household/close
Scabies Sarcoptes scabiei Derbac M liquid Derbac M liquid contacts; machine wash clothes, towels and
bed linen.

Author/s: Dr Caroline Kavanagh, Caroline Hallam, Dr Nandu Thalange, Dr Catherine Tremlett, Dr Bron Hennebry Date of issue: March 2015
Valid until: March 2018 Guideline Ref No (CA5084) v 2.1
Document: Trust Antibiotic Policy for the Management of Common Infections in Paediatrics
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Trust Antibiotic Policy for the Empirical Management of Common Infections in Paediatrics

Soft Tissue Infections Continued


Common Penicillin Allergy
Infection First Line Notes
Organisms (Also See guidance notes)
If suspected MRSA use vancomycin
Flucloxacillin IV/PO Cefuroxime IV+ Metronidazole IV/PO
Use co-amoxiclav if gram negative cover
OR
If history of penicillin anaphylaxis required.
Staphylococcus aureus Vancomycin IV
Surgical site infection Streptococci OR Vancomycin gentamicin IV Add metronidazole if anaerobic cover
required or dirty surgery.
Co-Amoxiclav IV/PO metronidazole IV/PO
7 days 7 days
Caution! Potential toxicity
Always discuss with microbiologist
Ceftriaxone IV + Clindamycin IV regarding management and duration of
Group A Streptococcus Ceftriaxone IV If history of penicillin anaphylaxis therapy. Surgical debridement essential.
Necrotising fasciitis Anaerobes + Clindamycin IV Vancomycin IV + Clindamycin IV+
Gram negative bacilli
Ciprofloxacin IV/PO invasive Group A streptococcal
disease is notifiable
Staphylococci Consider need for tetanus booster/
Streptococci
Co-amoxiclav PO Clindamycin PO immunoglobulin, blood borne virus risk,
Bites (animal or human) Pasteurella multocida
5 days 5 days and rabies prophylaxis for bites from
Eikenella corrodens
Anaerobes endemic areas.
Azithromycin PO Azithromycin PO Approval from DTMM Chair (or deputy)
Cat Scratch Fever Bartonella hensellae
5 days required for this indication.
5 days

Respiratory Tract Infections (In known or suspected immunodeficiency, obtain expert advice)
Common Penicillin Allergy
Infection First Line Notes
Organisms (Also See guidance notes)

Streptococcus pneumoniae Amoxicillin PO Clarithromycin PO Consider erythromycin or ciprofloxacin if


Uncomplicated 7-10 days clarithromycin not tolerated.
Haemophilus influenzae Clarithromycin PO
Community acquired Moraxella catarrhalis 7-10 days
(Switch to Co-amoxiclav PO where no Remember to send investigations for viral
Pneumonia Atypical bacteria clinical response after 48 hours) and atypical organisms where appropriate.
Clarithromycin PO
Mycoplasma pneumoniae 14 days
Atypical Pneumonia Chlamydia pneumoniae Consider erythromycin or ciprofloxacin if
Chlamydia psittaci Clarithromycin PO If history of penicillin anaphylaxis clarithromycin not tolerated.
14 days
Legionella is a Notifiable Coxiella burnetii
Legionella pneumophila
Ciprofloxacin IV/PO
Remember to send investigations for viral
Disease + Rifampicin PO if Legionella suspected + Rifampicin PO if Legionella suspected and atypical organisms where appropriate.

Author/s: Dr Caroline Kavanagh, Caroline Hallam, Dr Nandu Thalange, Dr Catherine Tremlett, Dr Bron Hennebry Date of issue: March 2015
Valid until: March 2018 Guideline Ref No (CA5084) v 2.1
Document: Trust Antibiotic Policy for the Management of Common Infections in Paediatrics
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Trust Antibiotic Policy for the Empirical Management of Common Infections in Paediatrics

Respiratory Tract Infections Continued


Common Penicillin Allergy
Infection First Line Notes
Organisms (Also See guidance notes)
Benzylpenicillin IV + Clarithromycin PO Switch patient to co-amoxiclav regimen or
Streptococcus pneumoniae (Use if lobar pneumonia, and Strep. Cefotaxime IV+ Clarithromycin PO
Moderate/Severe Add flucloxacillin if staphylococcus
Haemophilus influenzae pneumoniae suspected) If history of penicillin anaphylaxis
Community acquired Moraxella catarrhalis OR
suspected (e.g. after flu outbreak).
Pneumonia Clarithromycin IV/PO Consider parapneumonic effusion if not
Atypical bacteria Co-Amoxiclav IV/PO + Clarithromycin PO 7-10 days
7-10 days resolving.
Ceftazidime IV + Gentamicin IV
Streptococcus pneumoniae If history of penicillin anaphylaxis
Haemophilus influenzae Clarithromycin PO + Gentamicin IV
Moderate/Severe Hospital
acquired pneumonia
Moraxella catarrhalis
Atypical bacteria
Tazocin IV
7-10 days
OR Caution! Potential toxicity
Gram negative bacilli Vancomycin + Gentamicin IV if MRSA
Pseudomonas suspected or isolated
7-10 days
Consider drainage as an adjunctive
Co-Amoxiclav IV + therapy wherever possible.
Cefotaxime IV + Clarithromycin PO
Streptococcus pneumoniae
Clarithromycin PO
If history of penicillin anaphylaxis Switch to oral therapy as soon as clinically
(majority of cases) Benzylpenicillin can be used if
Parapneumonic effusion / Staphylococcus aureus Vancomycin IV appropriate. Discuss duration with Chest
Empyema streptococcus strongly suspected or team and Microbiology.
(especially if < 1 year or (Consider adding metronidazole +
proven.
empyema) gentamicin if gut organisms likely to be Requires Respiratory Clinic follow-up.
Vancomycin IV if MRSA suspected, or
implicated) See Parapneumonic Effusion Guideline on
patient known to be colonised
intranet

Always Seek Specialist Advice


Cystic Fibrosis
See CF Network Guidelines on intranet

Cotrimoxazole IV infusion Cotrimoxazole IV infusion Patients with HIV infection.


Pneumocystis jiroveci Pneumocystis jiroveci
OR OR Discuss with HIV consultant.
Pneumonia (PcP) Pentamidine isethionate if Cotrimoxazole Pentamidine isethionate if Cotrimoxazole Treatment duration of 21 days, at least 14
not tolerated not tolerated days of which should be intravenous.
Ceftriaxone IV
Ceftriaxone IV If history of penicillin anaphylaxis Involve anaesthetic and ENT teams
Haemophilus influenzae B
Epiglottitis/Tracheitis Staphylococcus aureus Meropenem IV promptly if clinical suspicion of epiglottitis
5-7 days or tracheitis.
5-7 days

Author/s: Dr Caroline Kavanagh, Caroline Hallam, Dr Nandu Thalange, Dr Catherine Tremlett, Dr Bron Hennebry Date of issue: March 2015
Valid until: March 2018 Guideline Ref No (CA5084) v 2.1
Document: Trust Antibiotic Policy for the Management of Common Infections in Paediatrics
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Trust Antibiotic Policy for the Empirical Management of Common Infections in Paediatrics

Respiratory Tract Infections Continued


Common Penicillin Allergy
Infection First Line Notes
Organisms (Also See guidance notes)
Consider erythromycin or ciprofloxacin if
clarithromycin not tolerated. Reduces
Whooping Cough/ Bordatella pertussis Clarithromycin PO Clarithromycin PO infectivity but not severity of illness.
Pertussis B. paraperpertussis 7 days 7 days
Pertussis is a Notifiable disease

ENT Infections
Common Penicillin Allergy
Infection First Line Notes
Organisms (Also See guidance notes)
Bacteroides spp
Peptostreptococcus spp Ceftriaxone IV + Involve anaesthetic and ENT teams
Fusobacterium spp Metronidazole IV promptly if clinical suspicion of
alpha- and gamma- Ceftriaxone IV +
Metronidazole IV retropharyngeal abscess.
Retropharyngeal abscess haemolytic streptococci, If history of penicillin anaphylaxis
Staphylococcus aureus
Haemophilus spp
5-7 days Meropenem IV invasive Group A streptococcal
5-7 days disease is a Notifiable Disease.
Group A Streptococci
Most uncomplicated cases resolve without
Pharyngitis/ Tonsillitis Amoxicillin PO antibiotics, which should NOT routinely be
Scarlet Fever is a Group A Streptococcus OR
Cefradine capsules/Cefalexin elixir PO PO
Clarithromycin PO
10 days
used.
Notifiable disease 10 days DO NOT USE amoxicillin in suspected
glandular fever due to risk of rash.
Amoxicillin PO
Streptococcus pneumoniae Most uncomplicated cases resolve without
Switch to
Haemophilus influenzae Clarithromycin PO
Acute otitis media Moraxella catarrhalis Co-Amoxiclav PO where no clinical 5 days
antibiotics, which should NOT routinely be
Group A Streptococcus response after 48 hours used.
5 days
Clarithromycin PO
(IV if oral route not tolerated)
Streptococcus pneumoniae OR
Haemophilus influenzae Co-Amoxiclav PO/IV Clindamycin PO if anaerobic cover
Sinusitis Moraxella catarrhalis required (IV if oral route not tolerated)
Gram negative bacilli 7-10 days
OR
Anaerobes Cefuroxime IV + Metronidazole PO (if no
history of penicillin anaphylaxis)
7-10 days

Author/s: Dr Caroline Kavanagh, Caroline Hallam, Dr Nandu Thalange, Dr Catherine Tremlett, Dr Bron Hennebry Date of issue: March 2015
Valid until: March 2018 Guideline Ref No (CA5084) v 2.1
Document: Trust Antibiotic Policy for the Management of Common Infections in Paediatrics
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Trust Antibiotic Policy for the Empirical Management of Common Infections in Paediatrics

Central Nervous System Infections

Common Penicillin Allergy


Infection First Line Notes
Organisms (Also See guidance notes)
Streptococcus milleri Ceftriaxone IV + Metronidazole IV Ceftriaxone IV+ Metronidazole IV Treat jointly with neurosurgeons.
Anaerobes
If history of penicillin anaphylaxis discuss Monitor with repeated scans to verify
Brain abscess Gram negative bacilli
with microbiology
Streptococcus pneumoniae 4-6 weeks disappearance of the ring enhancing
Haemophilus influenzae 4-6 weeks capsule.
IV for whole duration
Treat for 21 days if:
Any choreoathetoid movements
Herpes Simplex Virus In children <18 months.
(HSV) If persistent EEG or MRI abnormities
Varicella Zoster Virus
Acyclovir can be stopped if :
Infective encephalitis (VZV)
Parechovirus
Aciclovir IV if suspected HSV or VZV Aciclovir IV The child is clinically back to normal
Notifiable disease Mycoplasma Tuberculosis
14-21 days (see notes) 14 -21 days (see notes) CSF HSV PCR negative after >72hrs
Mycoplasma Pneumoniae and low index of suspicion
Other viruses The EEG is normal
Other bacteria Cranial imaging is normal after 5-7
days
Consider 2nd LP if clinically indicated (initial
HSV PCR DNA can be falsely negative).
Cefotaxime IV
Group B streptococcus Cefotaxime IV + Gentamicin IV Consider possibility of herpes encephalitis
Meningitis (add Amoxicillin IV if Listeria suspected)
E. coli and the need for acyclovir.
(1-3 months of age) Streptococcus pneumoniae If history of penicillin anaphylaxis
10-21 days For infants under 1 month use amoxicillin
Chloramphenicol IV + Gentamicin IV
Notifiable Disease Haemophilus influenzae
Listeria monocytogenes Consider adding Dexamethasone IV 10-21 days & cefotaxime (refer to NICE guidance CG
0.15mg/kg qds if no features of shock 149, August 2012).
Ceftriaxone IV Ceftriaxone IV Notifiable disease.
5-14 days depending on organism
3 months of age Modify choice according to bacteriology
Meningitis (3 months) Consider adding Dexamethasone IV
Antibiotic prophylaxis for household
Neisseria meningitidis results contacts.
Notifiable Disease Streptococcus pneumoniae
Haemophilus influenzae
0.15mg/kg qds if no features of shock
If history of penicillin anaphylaxis Do not await specimens before giving
Modify choice according to bacteriology Chloramphenicol IV antibiotics.
results 5-14 days depending on organism
Staphylococcus aureus, Ceftriaxone IV Discuss duration of therapy with
Ventriculo-Peritoneal Acinetobacter spp. neurosurgical team and microbiology.
Coagulase negative
Ceftriaxone IV If history of penicillin anaphylaxis
Shunt Infection Modify choice according to bacteriology
staphylococci Chloramphenicol IV results.

Author/s: Dr Caroline Kavanagh, Caroline Hallam, Dr Nandu Thalange, Dr Catherine Tremlett, Dr Bron Hennebry Date of issue: March 2015
Valid until: March 2018 Guideline Ref No (CA5084) v 2.1
Document: Trust Antibiotic Policy for the Management of Common Infections in Paediatrics
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Trust Antibiotic Policy for the Empirical Management of Common Infections in Paediatrics

Gastrointestinal/Abdominal Infections
Common Penicillin Allergy
Infection First Line Notes
Organisms (Also See guidance notes)
Discuss all cases with infection control/
microbiology.
Pseudomembranous/ Metronidazole PO Metronidazole PO rd
OR OR Use Vancomycin only if 3 or subsequent
Antibiotic Associated Clostridium difficile episode of infection, for severe infection,
Vancomycin PO Vancomycin PO
Colitis 7-10 days 7-10 days for infection not responding to
Metronidazole, or in children intolerant of
Metronidazole.

E. Coli 0157 infection Escherichia coli Antibiotics not recommended Antibiotics not recommended Haemolytic Uraemic Syndrome is a
Notifiable Disease
Usually settles without treatment.
Erythromycin PO Erythromycin PO Treat severe infection. Prolonged course
Campylobacter enteritis of antibiotics may be required.
Campylobacter Spp OR OR
Ciprofloxacin PO Ciprofloxacin PO Infectious Bloody Diarrhoea is a
Notifiable Disease
Ciprofloxacin PO/IV
OR Approval from DTMM Chair (or deputy)
Ciprofloxacin PO
Invasive Samonellosis/ Azithromycin required for this indication.
OR
Salmonella spp OR
Typhoid fever Azithromycin PO
Cefotaxime IV (if no history of penicillin Enteric fever and Infectious Bloody
Discuss duration with microbiology anaphylaxis) Diarrhoea are Notifiable Diseases
Discuss duration with microbiology
Ciprofloxacin PO Ciprofloxacin PO Treat severe infection.
Dysentery Shigella spp OR OR Infectious Bloody Diarrhoea is a
Cefotaxime IV Cefotaxime IV Notifiable Disease
Amoebiasis Increase duration of therapy if extra-
Metronidazole PO Metronidazole PO
Infectious bloody Entamoeba histolytica
5 days 5 days
intestinal infection present (e.g. liver
diarrhoea is notifiable abscess).

Metronidazole PO Metronidazole PO
Giardiasis Giardia lamblia
5 days 5 days

Amoxicillin PO + Metronidazole PO +
Clarithromycin OR Metronidazole+ Clarithromycin+
Helicobacter Helicobacter pylori Proton Pump inhibitor (e.g. Omeprazole) Proton Pump Inhibitor (e.g. Omeprazole) High rates of resistance to Clarithromycin.
10-14 days 10-14 days
Author/s: Dr Caroline Kavanagh, Caroline Hallam, Dr Nandu Thalange, Dr Catherine Tremlett, Dr Bron Hennebry Date of issue: March 2015
Valid until: March 2018 Guideline Ref No (CA5084) v 2.1
Document: Trust Antibiotic Policy for the Management of Common Infections in Paediatrics
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Trust Antibiotic Policy for the Empirical Management of Common Infections in Paediatrics

Gastrointestinal/Abdominal Infections Continued


Common Penicillin Allergy
Infection First Line Notes
Organisms (Also See guidance notes)
Gram negative bacilli Cefuroxime IV 20mg/kg &
If local inflammation/exudate noted
Uncomplicated Streptococci (e.g. S. Metronidazole IV 7.5mg/kg Same as First Line
peri-operatively, 3 doses are
Appendicitis milleri Anaerobes
recommended
Enterococci Single dose peri-operatively
Cefuroxime IV 20mg/kg
Amoxicillin 30mg/kg tds (dose may (avoid if there is history of
be doubled if clinically septic, to a penicillin anaphylaxis and discuss
maximum of 1g), AND suitable alternative therapy with
microbiologist) AND
Complicated Appendicitis Gentamicin 7mg/kg once daily
(perforated or (adjusted to serum levels) AND
Gram negative bacilli Gentamicin 7mg/kg once daily
gangrenous)
Anaerobes Metronidazole 7.5mg/kg tds (max (adjusted to serum levels) AND .
Complicated Appendicitis
Enterococci 500mg)
(perforated or
Metronidazole 7.5mg/kg tds (max
gangrenous)
Duration 3 5 days 500mg)

Review at 48hr and consider Duration to be reviewed according


changing to oral if afebrile and to clinical response and
tolerating diet microbiological advice
Cefuroxime IV 20mg/kg
Amoxicillin 30mg/kg tds (dose may
(avoid if there is history of
be doubled if clinically septic, to a
penicillin anaphylaxis and discuss
maximum of 1g), AND
Gram negative bacilli suitable alternative therapy with
S. milleri microbiologist) AND
Appendix Mass/ Gentamicin 7mg/kg once daily
Anaerobes
Intra-abdominal abscess/ (adjusted to serum levels) AND
Enterococci Gentamicin 7mg/kg once daily
collection
(adjusted to serum levels) AND
Metronidazole 7.5mg/kg tds (max
Peritonitis 500mg)
Metronidazole 7.5mg/kg tds (max
500mg)
Duration to be reviewed according
to clinical response and
Duration to be reviewed according
microbiological advice
to clinical response and
microbiological advice
Author/s: Dr Caroline Kavanagh, Caroline Hallam, Dr Nandu Thalange, Dr Catherine Tremlett, Dr Bron Hennebry Date of issue: March 2015
Valid until: March 2018 Guideline Ref No (CA5084) v 2.1
Document: Trust Antibiotic Policy for the Management of Common Infections in Paediatrics
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Trust Antibiotic Policy for the Empirical Management of Common Infections in Paediatrics

Endocarditis (Management of endocarditis requires specialist Cardiology & Microbiology advice)


Common Penicillin Allergy
Infection First Line Notes
Organisms (Also See guidance notes)
Endocarditis (no cardiac Duration of treatment should be in
prosthesis)
Flucloxacillin IV + Gentamicin IV Vancomycin + Gentamicin IV discussion with a Paediatric Cardiologist.
Staphylococcus aureus
Streptococcus viridans HACEK Haemophilus, Actinobacillus,
Vancomycin IV + Gentamicin
Enterococcus faecalis Cardiobacterium, Eikenella, Kingella
Endocarditis (cardiac HACEK Organisms Vancomycin IV + Gentamicin IV
prosthesis) + Rifampicin PO + Rifampicin PO
Caution! Potential toxicity

Author/s: Dr Caroline Kavanagh, Caroline Hallam, Dr Nandu Thalange, Dr Catherine Tremlett, Dr Bron Hennebry Date of issue: March 2015
Valid until: March 2018 Guideline Ref No (CA5084) v 2.1
Document: Trust Antibiotic Policy for the Management of Common Infections in Paediatrics
Copy of complete document available from: Trust Intranet Page 13 of 16
Trust Antibiotic Policy for the Empirical Management of Common Infections in Paediatrics

Bacteraemia & Septicaemia


Common Penicillin Allergy
Infection First Line Notes
Organisms (Also See guidance notes)
Consider port of entry.
Group A streptococcus Cefotaxime IV
Add Vancomycin if MRSA suspected, or
Haemophilus Cefotaxime IV OR
Septicaemia OR Ceftriaxone IV known MRSA colonisation.
Meningococcus Ceftriaxone IV
1 month to 16 years Staphylococcus aureus
5-7 days
5-7 days
If history of penicillin anaphylaxis discuss
Invasive Group A streptococcus
Streptococcus pneumoniae and Meningococcus are notifiable
Coliforms with microbiology
diseases
Give IV antibiotics within one hour of
arrival DO NOT DELAY
Coagulase negative
Febrile neutropenia with staphylococcus Prophylaxis continue Co-trimoxazole
19 prophylaxis. Continue antifungal
Indwelling cannula Staphylococcus aureus
Meropenem IV + Vancomycin IV
Group A streptococcus Tazocin IV + Vancomycin IV
OR OR
prophylaxis.
Stop penicillin V / Ciprofloxacin
Invasive Group A Gram negative bacilli
Haemophilus influenzae Meropenem IV+ Vancomycin IV (see If history of penicillin anaphylaxis
prophylaxis.
streptococcus and Streptococcus pneumoniae notes) Duration Treat as inpatient at least until
Ciprofloxacin PO/IV + Vancomycin IV
Meningococcus are Pseudomonas the results of blood cultures are known at
notifiable diseases
Neisseria meningitidis 48 hours and afebrile for 48 hours.
Systemically unwell clinically
septicaemic: Add ONCE DAILY
gentamicin at any time if child becomes
unwell. If in doubt give one dose. Measure
nd
Febrile neutropenia Staphylcoccus aureus trough levels. Omit 2 dose if renal
without Indwelling Streptococcus pneumoniae impairment or toxic levels.
21 Haemophilus influenzae
cannula Meropenem IV Substitute Meropenem for Tazocin if:
Group A streptococcus Tazocin IV
OR High-dose IV methotrexate due to be
If history of penicillin anaphylaxis
Invasive Group A Gram negative bacilli
Meropenem IV
2 given or received within previous 48
streptococcus and Neisseria meningitidis Ciprofloxacin PO/IV+ Vancomycin IV hours,
Meningococcus are Coagulase negative ESBL Colonisation/infection in past
notifiable diseases staphylococcus Refer to Addenbrookes policy (link
here) for further details and for advice
on review at 48-72 hours.

Author/s: Dr Caroline Kavanagh, Caroline Hallam, Dr Nandu Thalange, Dr Catherine Tremlett, Dr Bron Hennebry Date of issue: March 2015
Valid until: March 2018 Guideline Ref No (CA5084) v 2.1
Document: Trust Antibiotic Policy for the Management of Common Infections in Paediatrics
Copy of complete document available from: Trust Intranet Page 14 of 16
Trust Antibiotic Policy for the Empirical Management of Common Infections in Paediatrics

Eye Infections
Common Penicillin Allergy
Infection First Line Notes
Organisms (Also See guidance notes)
Ofloxacin 0.3% eye drops 2 hourly + Ofloxacin 0.3% eye drops 2 hourly + Ophthalmia Neonatorum is a
Neisseria gonorrhoea: Neisseria gonorrhoea: Notifiable Disease
Cefotaxime IV Cefotaxime IV Treatment depends on results of gram
Opthalmia neonatorum Neisseria gonorrhoeae
Chlamydia: Chlamydia: stain: If N. gonorrhoea suspected treat
Chlamydia
Herpes Erythromycin PO 14 days Erythromycin PO 14 days promptly before results of gram stain are
back. Otherwise treat empirically as
Herpes Simplex: Herpes Simplex: Chlamydia.
Aciclovir IV and acyclovir eye ointment Aciclovir IV tds and acyclovir eye Specific swabs are available for
5 x day for 5 days ointment 5 x day for 5 days Chlamydia and viral culture.
Staphylococcus aureus, Chloramphenicol eye drops 0.5% 2 Chloramphenicol eye drops 0.5% 2
Haemophilus influenzae, hourly OR hourly OR
Acute Purulent Streptococcus pneumoniae Fucithalmic eye drops 1% bd Fucithalmic eye drops 1% bd
Conjunctivitis Ofloxacin 0.3% eye drops OR Ofloxacin 0.3% eye drops OR
Pseudomonas aeruginosa
Levofloxacin 0.5% eye drops Levofloxacin 0.5% eye drops

Uncomplicated Streptococcus pyogenes Children 3y or over with periorbital


Staphylococcus aureus Co-Amoxiclav PO Clarithromycin PO oedema and erythema only.
Periorbital Cellulitis Haemophilus influenzae 7 days 7 days Children aged under 3yrs must be treated
(Age 3yrs-16yrs only) Streptococcus pneumoniae as a complicated case.
Ceftriaxone IV + Metronidazole PO
Streptococcus pyogenes Ceftriaxone IV + Metronidazole PO Joint management with Ophthalmology
Complicated Periorbital In truly penicillin allergic patients and ENT required.
Staphylococcus aureus OR
Cellulitis Haemophilus influenzae Co-Amoxiclav IV Vancomycin IV + Gentamicin IV + Total of 10 days antibiotics required.
(All Ages) Streptococcus pneumoniae 10 days Metronidazole IV Caution! Potential toxicity
10 days

Author/s: Dr Caroline Kavanagh, Caroline Hallam, Dr Nandu Thalange, Dr Catherine Tremlett, Dr Bron Hennebry Date of issue: March 2015
Valid until: March 2018 Guideline Ref No (CA5084) v 2.1
Document: Trust Antibiotic Policy for the Management of Common Infections in Paediatrics
Copy of complete document available from: Trust Intranet Page 15 of 16
Trust Antibiotic Policy for the Empirical Management of Common Infections in Paediatrics

References/ source documents


1. NICE guideline CG54, August 2007 : Urinary tract infection in children
2. Pelvic inflammatory disease. Soper DE. Obstetrics and Gynaecology 2010:116: 419
3. Antibiotic Treatment for acute pelvic inflammatory disease. Walker CK et al. Clinical Infectious
Diseases Journal 2007: 44 Supplement 3: S111
4. Management of sexually transmitted infections in pubertal children. Logan Manikam, et al.Arch
Dis Child Educ Pract Ed 2012;97:4 132-142
5. The management of septic arthritis in children: systematic review. Kang SN, Sanghera T et al. J
Bone Joint Surg Br. 2009;91(9):1127.
6. Practice guidelines for the diagnosis and management of skin and soft-tissue infections. Stevens
DL et al. Infectious Diseases Society of America. Clin Infect Dis. 2005;41(10):1373.
7. BTS Guidelines for the Management of Community Acquired Pneumonia in Childhood. British
Thoracic Society Standards of Care Committee. Thorax 2002; 57: 1-24.
8. The Child with HIV and respiratory illness. CHIVA guideline 2001
9. BTS guidelines for the management of pleural infection in children. Balfour-Lynn IM, Abrahamson E,
Cohen G et al. Thorax 2005; 60 (Suppl 1): i1-i21.
10. Guideline for the management of pleural infection in children. RCPCH Guideline Appraisal, British
Thoracic Society, Published 2004, RCPCH.
11. NICE guideline CG102, June 2010, Bacterial meningitis and meningococcal septicaemia.
12. Dexamethasone as adjunctive therapy in bacterial meningitis. A meta-analysis of clinical trials.
McIntyre et al. JAMA Sept 1997 278: 925-31
13. Review of the NICE guidance on bacterial meningitis and meningococcal septicaemia . Ruth H
Radcliffe Arch Dis Child Educ Pract Ed 2011;96:6 234-237
14. Encephalitis in Children. Thompson et al. Archives of Diseases in childhood. June 2008
15. East of England Childrens Cancer Network: Supportive Care Guidelines for Paediatric
Haematology and Oncology Shared Care, August 2011
16. Joshua Bedwell and Nancy M.Bauman,(2011)current opinion in otolaryngology , head and neck
surgery 19 467 473
17. Andrea Hauser, Simone Fogarasi( 2010), periorbital and orbital cellulitis, paediatrics in review
31 242-249
18. NICE guideline CG47, May 2007: Feverish illness in children

Author/s: Dr Caroline Kavanagh, Caroline Hallam, Dr Nandu Thalange, Dr Catherine Tremlett, Dr Bron Hennebry Date of issue: March 2015
Valid until: March 2018 Guideline Ref No (CA5084) v 2.1
Document: Trust Antibiotic Policy for the Management of Common Infections in Paediatrics
Copy of complete document available from: Trust Intranet Page 16 of 16

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