Welcome to the Alder Hey Antimicrobial Guide mobile app.

These guidelines have been developed for use at Alder Hey when antimicrobial treatment is being considered. Although every effort has been made to keep these guidelines updated, healthcare professionals have the responsibility to be fully aware of current best practice and to use good clinical judgement in using the tool with individual patients. By using this tool you agree with the licence terms, which can be found here.

The infectious diseases / microbiology team can be contacted via switchboard for advice if required.

Disclaimer

These Antimicrobial Guidelines have been developed by Alder Hey NHS Foundation Trust for use internally at Alder Hey NHS Foundation Trust with patients where antimicrobial treatment is being considered.

The guidelines are provided for use by appropriately qualified professionals and the making of any decision regarding the suitability of appropriate health care support and, of a particular treatment or therapy for a patient, is the responsibility of and subject to the user’s professional judgement. Whilst every reasonable care has been taken to ensure the accuracy and suitability of the tool for antimicrobial prescribing, neither the author nor the publisher can accept any responsibility for any action taken, or not taken, on the basis of this information.

Use of the Alder Hey Antimicrobial Guidelines is not a substitute for the exercise of appropriate professional skill and judgement.

Alder Hey NHS Foundation Trust shall not be liable to any person for any loss or damage which may arise from the use of the Alder Hey Antimicrobial Guidelines or any amended version of the Guidelines whether authorised or not.

Nothing in the above disclaimer shall restrict or exclude liability for death or personal injury caused by the negligence of Alder Hey NHS Foundation Trust.

Limitations

The Alder Hey Antimicrobial Guidelines are up to date as at June 2021. The Guidelines may become out of date over time, requiring modification or replacement as new data and protocols are published. Healthcare professionals have the responsibility to be fully aware of current best practice and to use good clinical judgement in using the tool with individual patients.

Copyright

The Antimicrobial Guidelines are © 2023 Alder Hey NHS Foundation Trust. All Rights Reserved. Not to be amended, circulated or reproduced in whole or in part or in any form without the permission of the copyright holder.

Other than for internal use and distribution the Alder Hey Antimicrobial Guidelines may not be circulated or reproduced in whole or in part without the prior written permission of Alder Hey NHS Foundation Trust.

Terms of use

The Alder Hey NHS Foundation Trust materials may be used only under the terms set out in this document. Any unauthorised copying or reproduction or use of the Alder Hey Antimicrobial Guidelines materials may give rise to a claim for damages. Use of the Alder Hey Antimicrobial Guidelines materials is subject to the laws of England.

IF YOU DO NOT AGREE TO THE ABOVE YOU ARE NOT AUTHORISED TO USE THIS TOOL AND MUST DELETE ALL COPIES OF THE SOFTWARE APPLICATION.

INTRODUCTION

Intravenous (IV) to oral switch therapy is the prompt conversion of IV antibiotic therapy to oral antibiotic therapy. In many cases patients may be considered candidates for switching from IV to oral therapy once the patient has shown clinical improvement and is medically stable.

This guideline is intended for:

• use with the Antibiotic Guidelines available on the Intranet
• promotion of the timely switch from IV to oral antibiotic therapy

Advantages of prompt switch to oral therapy include:

• Improved patient comfort and mobility
• Reduced length of stay in hospital
• Saving of medical and nursing time
• Potential to reduce treatment costs
• Reduction in infected IV lines sites
• Patient is more likely to receive antibiotics at the correct time

All children receiving IV antibiotics should be reviewed using the COMH considerations daily:

• Clinical improvement observed
• Oral route not compromised (i.e. NONE of: vomiting, NBM, severe diarrhoea, swallowing disorder, unconscious). For NG/PEG feeding - consult your Pharmacist for a suitable oral formulation.
• Markers show a trend towards normal for at least 24 hours:
  • Temperature >36oC and <38oC
  • White cell count and CRP showing a trend towards normal
  absence of these tests should not impede switch if all other criteria met.
• High risk infections (see below)

Senior Clinician or Microbiologist has specifically advised a longer IV duration as infection is classified as high risk. High-risk infections: warrant prolonged IV therapy to optimise response and minimise risk of relapse. Discuss with Infectious Diseases Team/Microbiology before switching such patients to oral therapy. Examples of high risk infections include:

• Bone/Joint infection
• Empyema
• Exacerbation of cystic fibrosis
• Endocarditis
• Mediastinitis
• Inadequately drained abscess
• Liver abscess
• Staphylococcus aureus bacteraemia
• Severe or necrotising soft tissue infections
• Febrile neutropenia
• Infected implants/prosthetics
• Central venous catheter infection
• Meningitis
• Intracranial abscesses

Selection of oral antibiotics should be based on the Antibiotic Guidelines (see Intranet) or reported sensitivities from relevant microbiology specimens. Contact the Infectious Diseases Team/Microbiology for further advice.

References: 1. www.bsac.org.uk/pyxis. 2. Sevinc F et al. ‘Early switch from intravenous to oral antibiotics: Guidelines and Implementation in a large teaching hospital.’ JAC 1999; 43: 601-666.

Approved by DTC: 10th September 2010 (v1) Author(s): A Riordan, D Sharpe

The primary treatment of necrotising fasciitis is surgical debridement and urgent surgical opinion should be sought if suspected.

All ages

Likely causative organisms:

• Clostridium perfringens
• Group A Streptococcus
• Staphylococcus aureus
• Escherichia coli

Choice of antibiotic:

IV Cefotaxime
+ IV clindamycin

Start antibiotics within 1 hour of diagnosis for life threatening infections.

Refer to BNFc and use maximum doses according to age and weight.

Duration of therapy:

10 days

Notes:

Review in light of culture results.

All ages

Likely causative organisms:

Polymicrobial:

• Pasteurella spp.
• Staphylococcus aureus
• Streptococcus spp.
• Anaerobes

Choice of antibiotic:

Oral / IV Co-amoxiclav

Duration of therapy:

5 days

Notes:

Check tetanus status, and review need for tetanus booster dose and tetanus immunoglobulin.

If penicillin allergic: consider Clarithromycin plus Metronidazole.

Approved by Medicines Management Committee, May 2017.

≤ 5 days after burn (or 6-9 days and no recent antibiotics)

Likely causative organisms:

• Staphylococcus aureus
• Group A Streptococcus
• Gram negative bacilli

Choice of antibiotic:

IV Cefuroxime
If toxic shock: add IV Clindamycin

Cefuroxime: 50mg/kg (max 1.5g) every 6 – 8 hrs (refer to BNFc for neonates < 21 days old)

Clindamycin: 10mg/kg (max 1.2g) every 6 hours. (Refer to BNFc for neonates)

Duration of therapy:

5 - 10 days

≥ 10 days after burn (or 6-9 days and recent antibiotics)

Likely causative organisms:

• As above plus...
• MRSA
• Pseudomonas aeruginosa

Choice of antibiotic:

IV Vancomycin + IV Ceftazidime
If toxic shock: add IV Clindamycin

Vancomycin: Refer to local dosing and monitoring guidelines.

Ceftazidime: 50mg/kg (max 2g) every 8 hours. Refer to BNFc for neonates < 21days.

Clindamycin: 10mg/kg (max 1.2g) every 6 hours. (Refer to BNFc for neonates)

Duration of therapy:

5 - 10 days

Notes:

If the patient has been in a hospital in another country in the previous 12 months (Not North America, Northern Europe or Australasia) discuss with Microbiology/ Infectious Diseases.

Refer to Treatment of infections in children in hospital with burns guideline.

Approved by Medicines Management Committee, May 2017.

> 1 month

Cellulitis, erysipelas, furuncle, skin abcesses, impetigo:

Likely causative organisms:

• Staphylococcus aureus
• Group A Streptococcus

Choice of antibiotic:

Mild:

Oral cefalexin liquid or
Oral flucloxacillin capsules (if able to swallow)

Severe:

IV flucloxacillin*

Duration of therapy:

7 days

Notes:

*Alternative in penicillin allergy / MRSA carrier is oral/IV clindamycin. Due to poor palatability of clindamycin liquid consider co-trimoxazole if unable to swallow capsules.

Flucloxacillin and Clindamycin liquid have a very poor taste.

For children < 1 month please refer to BNFc dosing.

For MRSA check susceptibility results in lab.

BNFc 2012, Bugs and Drugs 2006, Red Book 29th Ed 2012, Sanford Guide to Antimicrobial Therapy 2010.

Approved by Medicines Management Committee, May 2017.

All ages

Likely causative organisms:

• Staphylococcus aureus
• Streptococcus pyogenes
• Streptococcus pneumoniae
• Haemophilus influenzae
• Anaerobes

Choice of antibiotic:

IV Cefotaxime*
+ add IV metronidazole if there is sinus disease or orbital cellulitis is suspected and refer urgently to ENT.

Duration of therapy:

7 - 10 days

Notes:

*Ensure Cefotaxime dose is optimised to 50mg/kg every 6 hours for CNS penetration.

Please refer to the Pre-Septal and Orbital Cellulitis Pathway

Patient should be referred urgently to ENT if orbital cellulitis is suspected.

Consider OPAT/switching to oral Co-amoxiclav when patient clinically improving. Refer to Micro/ID if penicillin allergic.

Approved by Medicines Management Committee, May 2017.

Birth to 1 month

Cellulitis, erysipelas, furuncle, skin abcesses, impetigo:

Likely causative organisms:

• Staphylococcus aureus
• Group A Streptococcus

Choice of antibiotic:

Mild:

Oral Cephalexin

Severe:

IV Cefotaxime
+ IV Flucloxacillin

Duration of therapy:

Mild: 7 days
Severe: 7 days

Notes:

Rationalise antibiotics for severe infections at 48 hours.

BNFc 2012, Bugs and Drugs 2006, Red Book 29th Ed 2012, Sanford Guide to Antimicrobial Therapy 2010.

Approved by Medicines Management Committee, May 2017.

All ages

Involving head, neck, trunk or extremity:

Likely causative organisms:

• Staphylococcus aureus
• Group A Streptococcus pyogenes

Choice of antibiotic:

Mild (minimal erythema / induration and/or pus):
Oral Cephalexin

Moderate / severe:
IV Cefuroxime

Duration of therapy:

Mild: 5 days
Severe: 7 days

Notes:

If penicillin allergic, use clindamycin PO / IV.

Clindamycin liquid unpalatable, consider opening capsules.

All ages

Involving axilla, perineum, female genital tract or GI tract:

Likely causative organisms:

Polymicrobial:

• Staphylococcus aureus
• Group A Streptococcus
• Enterobacteriaceae
• Anaerobes

Choice of antibiotic:

Mild:
Oral co-amoxiclav

Moderate - severe:
IV co-amoxiclav

Duration of therapy:

Mild: 5 days
Severe: 7 days

Notes:

If penicillin allergic, use oral/IV Clindamycin AND oral/IV Ciprofloxacin.

Clindamycin liquid unpalatable, consider opening capsules.

Please also refer to Urinary Tract In-patient Pathway or the Urinary Tract Out-patient Pathway as appropriate.

< 3 months

Treat as per sepsis (community acquired) guideline

> 3 months

Likely causative organisms:

• Enterobacteriacea

Choice of antibiotic:

Oral Cephalexin

Duration of therapy:

3 days

Notes:

The above is for patients with presumed normal anatomy.

If oral antibiotic cannot be used, administer IV Cefotaxime.

Trimethoprim is an alternative in cephalosporin allergy (unless already on trimethoprim prophylaxis).

Please also refer to Urinary Tract In-patient Pathway or the Urinary Tract Out-patient Pathway as appropriate.

< 3 months

Treat as per sepsis (community acquired) guideline

> 3 months

Likely causative organisms:

• Enterobacteriacea

Choice of antibiotic:

Oral Cephalexin or IV Cefotaxime depending on clinical severity.

Duration of therapy:

7 - 10 days

Notes:

If oral antibiotic cannot be used, administer IV Cefotaxime.

Ciprofloxacin is an alternative in Penicillin allergy or Cephalosporin allergy.

Always use a different antibiotic for treatment than that used for prophylaxis.

Antibiotic prophylaxis should not routinely be offered for a first time UTI, but may be considered in infant and children with recurrent UTI. Always use a different antibiotic for treatment than that used for prophylaxis.

> 1 month

Likely causative organisms:

• Group A Streptococcus

Choice of antibiotic:

Oral Amoxicillin or IV Benzylpenicillin

Duration of therapy:

7 days

Notes:

Treat patients with antibiotic only if Group A streptococcus infection suspected or confirmed. A rapid Group A streptococcus test for tonsillitis is available from the lab.

Use Clarithromycin (oral/IV) for 10 days if penicillin allergic.

Approved by Medicines Management Committee, May 2017

All ages

Likely causative organisms:

• Haemophilus influenzae
• Staphylococcus aureus
• Streptococcus pneumoniae

Choice of antibiotic:

IV Cefotaxime

Duration of therapy:

5 days

Notes:

Consider oral co-amoxiclav if well after 3 days of IV therapy unless culture and sensitivity results indicate otherwise, or clarithromycin if penicillin allergic.

If Haemophilus influenzae type b is the causative organism discuss the use of chemoprophylaxis for index case and close contacts with Public Health England: Monday-Friday 9.00 am-5.00 pm (excluding Bank Holidays) - 0344 225 0562 option 1. Out of Hours - On call cover 5.00 pm-9.00 am weekdays and all day at weekends and Bank Holidays - Call 0151 434 4819 - Ask for On-call Public Health

All ages

Likely causative organisms:

• Streptococcus pneumoniae
• Haemophilus influenzae

Choice of antibiotic:

Oral Amoxicillin

Duration of therapy:

5 days

Notes:

In patients who do not have severe otitis media, consider delayed antibiotic treatment (collected at parent's discretion after 72 hours if child has not improved).

Longer course may be required in very young children or in severe infection.

If penicillin allergic, use oral clarithromycin.

Approved by Medicines Management Committee, May 2017

> 1 month

Likely causative organisms:

• Pseudomonas spp.
• Escherichia coli
• Anaerobes
• Streptococcus spp.
• Haemophilus influenzae
• Moraxella catarrhalis
• Staphylococcus aureus

Choice of antibiotic:

Dependant on organism isolated, refer to ID / micro

Duration of therapy:

Minimum of 2 weeks

Notes:

Following treatment, patients should be observed for a period to monitor for signs of recurrence. If after 3 months post-treatment there are no signs of recurrence then no further treatment will be required.

Approved by Medicines Management Committee, May 2017

> 1 month

Likely causative organisms:

• Streptococcus spp.
• Haemophilus influenzae
• Moraxella catarrhalis
• Staphylococcus aureus
• Anaerobes

Choice of antibiotic:

IV Cefotaxime + IV Metronidazole

Cefotaxime: 50mg/kg (max 3g) every 6 hours. Metronidazole: refer to BNFc

Duration of therapy:

2 weeks

Notes:

Switch to oral co-amoxiclav once clinically improving, unless patient is penicillin allergic in which case refer to Infectious Diseases/Microbiology for oral stepdown.

Approved by Medicines Management Committee, May 2017

> 1 month

Likely causative organisms:

• Staphylococcus aureus
• Group A Streptococcus
• Anaerobes

Choice of antibiotic:

IV Co-amoxiclav

Duration of therapy:

7 days

Notes:

Draining the abscess is the best treatment.

Choice in penicillin allergy: Clarithromycin plus Metronidazole.

Approved by Medicines Management Committee, May 2017

> 1 month

Likely causative organisms:

• Staphylococcus aureus
• Group A Streptococcus
• Anaerobes

Choice of antibiotic:

Oral / IV Co-amoxiclav

Duration of therapy:

7 days

Notes:

Use IV for severe disease / unable to tolerate orals. Switch to oral when tolerating.

Choice in penicillin allergy: Clarithromycin plus Metronidazole.

Approved by Medicines Management Committee, May 2017

All ages

Likely causative organisms:

• Streptococcus pneumoniae
• Haemophilus influenzae

Choice of antibiotic:

Oral Amoxicillin

Duration of therapy:

5 days

Notes:

Patients presenting with symptoms for 10 days or less should not be offered antibiotics.

If penicillin allergic, use oral Clarithromycin.

Approved by Medicines Management Committee, June 2018

< 1 month

Treat as per Sepsis (community acquired) guideline.

> 1 month

Likely causative organisms:

• Streptococcus pneumoniae
• Haemophilus influenzae
• Mycoplasma pneumoniae
• Chlamydophila pneumoniae
• Anaerobes

Choice of antibiotic:

IV / oral Co-amoxiclav

If penicillin allergic: IV / oral ciprofloxacin + clindamycin**

Duration of therapy:

5 days

Notes:

**Avoid the use of clindamycin oral suspension as poor palatability, consider clindamycin capsules or metronidazole if a liquid is required.

All ages

Early onset (< 4 days hospitalisation): treat as per Community Acquired Pneumonia guidelines

Late onset (> 4 days hospitalisation): see below.

Likely causative organisms:

Often polymicrobial:

• Staphylococcus aureus
• Enterobacteriacae
• Pseudomonas spp.
• Anaerobes

Occasionally:

• Streptococcus pneumoniae
• Haemophilus influenzae

Choice of antibiotic:

IV Piperacillin / Tazobactam 90mg/kg (max 4.5g) every 6 hours

If penicillin allergic: IV Ciprofloxacin
+ IV Clindamycin

Duration of therapy:

5 days

Notes:

Check culture and sensitivity results for oral stepdown.

If there is previous carriage of Pseudomonas, consider previous culture and sensitivity results for oral stepdown. Otherwise the empirical choice for oral stepdown is co-amoxiclav.

If there is penicillin allergy, the empirical oral stepdown is oral ciprofloxacin plus oral clindamycin.

Avoid the use of clindamycin suspension as poor palatability, consider opening capsules or metronidazole liquid as an alternative.

< 1 month

Treat as per Sepsis (community acquired) guideline.

> 1 month

Likely causative organisms:

• Streptococcus pneumoniae
• Haemophilus influenzae
• Mycoplasma pneumoniae
• Chlamydophila pneumoniae

Choice of antibiotic:

Mild / moderate disease:

Oral Amoxicillin*

Severe disease:

Oral Amoxicillin
+ Oral Clarithromycin

Duration of therapy:

5 days

Notes:

Oral antibiotics are as effective as IV for the treatment of severe pneumonia. IV antibiotics should only be considered for patients unable to tolerate oral antibiotics.

*When bacterial pneumonia is associated with influenza or measles, Co-amoxiclav is recommended instead of amoxicillin.

In Mild / Moderate disease, clarithromycin is the second line treatment option in penicillin allergy or if there is no response to amoxicillin or co-amoxiclav after 48 hours.

See BTS Guidelines on management of community acquired pneumonia in children for further information

All ages

Likely causative organisms:

• Streptococcus pneumoniae
• Haemophilus influenzae
• Mycoplasma pneumoniae
• Chlamydia pneumoniae
• Anaerobes

Choice of antibiotic:

IV Cefuroxime 50mg/kg (max 1.5g) every 6 hours
+ IV Clindamycin 10mg/kg (max 1.2g) every 6 hours

Duration of therapy:

14 days

Notes:

Refer to Empyema pathway

Oral stepdown to Co-amoxiclav unless culture and sensitivities indicate otherwise.

Choice in penicillin allergy; Clarithromycin for IV and for oral stepdown

> 3 months

Applies if hospitalised for > 4 days and no central line in situ.

Likely causative organisms:

• Staphylococcus aureus
• Enterococcus spp.
• Enterobacteriaceae
• Pseudomonas spp.

Choice of antibiotic:

IV Teicoplanin + IV Ciprofloxacin

IV Teicoplanin: loading dose 10mg/kg (max 800mg) every 12 hours for 3 doses, followed 24 hours later by a maintenance dose of 10mg/kg (max 800mg) once daily.

IV Ciprofloxacin: refer to BNFc

Duration of therapy:

Review at 36-48 hours and consider stopping antibiotics.

Culture negative sepsis: Up to 5 days

Culture positive sepsis: See appropriate guidance below.

Notes:

Check previous microbiology results to determine if recent antibiotic resistant organisms have been identified and contact the Infectious Diseases / Microbiology team if:

• patient has a previous history of carriage or infection with antibiotic-resistant organisms (e.g. Extended Spectrum Beta-Lactamase (ESBL) expressing organisms)
• patient had prolonged/multiple antibiotic use in the previous 3 months
• patient has been overseas in the previous 3 months

Once causative organism is known (usually within 24 hours) antibiotic choice and duration should be amended if necessary.

Approved by Medicines Management Committee, June 2018.

< 3 months

Applies if hospitalised for > 4 days and no central line in situ.

Likely causative organisms:

• Staphylococcus aureus
• Enterococcus spp.
• Enterobacteriaceae
• Pseudomonas spp.

Choice of antibiotic:

IV Vancomycin + IV Ciprofloxacin

Vancomycin: refer to local Vancomycin Dosing and Monitoring Guidelines. Ciprofloxacin: refer to BNFc

Duration of therapy:

Review at 36-48 hours and consider stopping antibiotics.

Culture negative sepsis: Up to 5 days

Culture positive sepsis: See appropriate guidance below.

Notes:

Check previous microbiology results to determine if recent antibiotic resistant organisms have been identified and contact the Infectious Diseases / Microbiology team if:

• patient has a previous history of carriage or infection with antibiotic-resistant organisms (e.g. Extended Spectrum Beta-Lactamase (ESBL) expressing organisms)
• patient had prolonged/multiple antibiotic use in the previous 3 months
• patient has been overseas in the previous 3 months

Once causative organism is known (usually within 24 hours) antibiotic choice and duration should be amended if necessary.

Approved by Medicines Management Committee, June 2018.

> 1 month

Likely causative organisms:

• Escherichia coli
• Haemophilus influenzae
• Streptococcus pneumoniae
• Klebsiella spp.
• Salmonella spp.
• Staphylococcus aureus
• Neisseria meningitidis

Choice of antibiotic:

IV Cefotaxime 50mg/kg (max 3g) every 6 hours

Unless immunosupression: use oncology febrile neutropenia guidance on antimicrobials

Duration of therapy:

Review at 36-48 hours and consider stopping antibiotics.

Culture negative sepsis: up to 5 days

Culture positive sepsis: Seek ID advice

Notes:

Check previous microbiology results to determine if recent antibiotic resistant organisms have been identified and contact the Infectious Diseases / Microbiology team if:

• patient has a previous history of carriage or infection with antibiotic-resistant organisms (e.g. Extended Spectrum Beta-Lactamase (ESBL) expressing organisms)
• patient had prolonged/multiple antibiotic use in the previous 3 months
• the patient has been overseas in the previous 3 months

If IV access unavailable, if appropriate, prescribe IM ceftriaxone until IV access is obtained. For preterm neonates less than 41 weeks corrected gestational age ceftriaxone is contraindicated so prescribe IM cefotaxime instead.

Approved by Medicines Management Committee, June 2018.

Birth - 1 month

Likely causative organisms:

• Group B Streptococcus
• Escherichia coli
• Listeria monocytogenes
• Haemophilus influenzae
• Streptococcus pneumoniae
• Klebsiella spp.
• Salmonella spp.
• Staphylococcus aureus
• Enterococcus spp.

Choice of antibiotic:

IV Cefotaxime + IV Amoxicillin*

Duration of therapy:

Review at 36-48 hours and consider stopping antibiotics.

Culture negative sepsis: up to 5 days

Culture positive sepsis: Seek ID advice

Notes:

* Stop amoxicillin once listeria meningitis is excluded.

Check previous microbiology results to determine if recent antibiotic resistant organisms have been identified and contact the Infectious Diseases / Microbiology team if:

• patient has a previous history of carriage or infection with antibiotic-resistant organisms (e.g. Extended Spectrum Beta-Lactamase (ESBL) expressing organisms)
• patient had prolonged/multiple antibiotic use in the previous 3 months
• the patient has been overseas in the previous 3 months

If IV access unavailable, if appropriate, prescribe IM ceftriaxone until IV access is obtained. For preterm neonates less than 41 weeks corrected gestational age ceftriaxone is contraindicated so prescribe IM cefotaxime instead.

Approved by Medicines Management Committee, June 2018.

> 3 months

Likely causative organisms:

• Coagulase negative Staphylococcus
• Staphylococcus aureus
• Enterococcus
• Enterobacteriaceae

Choice of antibiotic:

IV Teicoplanin + IV Gentamicin

IV Teicoplanin: loading dose 10mg/kg (max 800mg) every 12 hours for 3 doses, followed 24 hours later by a maintenance dose of 10mg/kg (max 800mg) once daily.

IV Gentamicin: refer to local Aminoglycoside Dosing and Monitoring Guidelines.

Unless immunosupression: use oncology febrile neutropenia guidance on antimicrobials available on the intranet.

Duration of therapy:

10 - 14 days

Notes:

Check previous microbiology results to determine if recent antibiotic resistant organisms have been identified and contact the Infectious Diseases / Microbiology team if:

• patient has a previous history of carriage or infection with antibiotic-resistant organisms (e.g. Extended Spectrum Beta-Lactamase (ESBL) expressing organisms)
• patient had prolonged/multiple antibiotic use in the previous 3 months

Prompt removal of all non-tunnelled venous catheters associated with blood stream infection.

Review choice and duration of antibiotic therapy when culture and sensitivities are available and refer to Alder Hey’s Guidelines for the treatment of confirmed central venous catheter (CVC) infection if appropriate.

Approved by Medicines Management Committee, Feb 2017.

< 3 months

Likely causative organisms:

• Coag. negative Staphylococci
• Staphylococcus aureus
• Enterococcus spp.
• Enterobacteriaceae

Choice of antibiotic:

IV Vancomycin + IV Ciprofloxacin

Vancomycin: refer to local Vancomycin Dosing and Monitoring Guidelines. Ciprofloxacin: refer to BNFc

Duration of therapy:

7 - 14 days

Notes:

Check previous microbiology results to determine if recent antibiotic resistant organisms have been identified and contact the Infectious Diseases / Microbiology team if:

• patient has a previous history of carriage or infection with antibiotic-resistant organisms (e.g. Extended Spectrum Beta-Lactamase (ESBL) expressing organisms)
• patient had prolonged/multiple antibiotic use in the previous 3 months
• patient has been overseas in the previous 3 months

Repeat Blood Cultures should be taken from CVC when the laboratory calls to say there is a positive blood culture. Two positive blood cultures with the same organism are highly suggestive of CVC infection. Blood cultures (both CVC and peripheral) should also be repeated if fever persists and the child is not improving clinically.

Prompt removal of all non-tunnelled venous catheters associated with blood stream infection.

Review choice and duration of antibiotic therapy when culture and sensitivities are available and refer to Alder Hey’s Guidelines for the treatment of confirmed central venous catheter (CVC) infection if appropriate.

Approved by Medicines Management Committee, Feb 2017.

All ages

Choice of antibiotic:

1st line: Piperacillin/tazobactam
If signs of septic shock: add Gentamicin

Penicillin allergy: Meropenem

Consider adding teicoplanin if line associated sepsis

Duration of therapy:

Review at 48 hours

Notes:

Refer to Intranet for full guideline ‘Guidelines for the Management and Prevention of Infection in Oncology and Haematology Patients’.

Approved by Medicines Management Committee, Oct 2017.

> 5 years

Likely causative organism:

• Staphylococcus aureus
• Streptococcus spp.

Choice of antibiotic:

IV Flucloxacillin* 50mg/kg (max. 2g) every 6 hours

Duration of therapy:

3 weeks for septic arthritis.

4-6 weeks in unifocal osteomyelitis.

At least 6 weeks in complex osteomyelitis.

(Unifocal disease indicates “simple” disease at a single site, whereas Complex disease includes any of the following: multifocal, significant bone destruction, resistant or unusual pathogen, immunosuppression.)

Notes:

*IV Clindamycin in penicillin allergy.

In unifocal disease consider IV to oral switch after 48 hours

In complex disease consider IV to oral switch after 14 days unless there is significant bone destruction as this often requires more than 6 weeks of IV antibiotics.

Considerations for IV to oral switch: clinical improvement, afebrile and oral fluids and medication can be established and CRP<20 or decreased by 66% of the highest value.

Oral antibiotic choice based on microbiology culture and sensitivity results, or if an organism has not been identified, use cefalexin as an oral stepdown and use the maximum dose allowed according to age/weight.

3 months - 5 years

Likely causative organism:

• Staphylococcus aureus
• Group A Streptococcus
• Kingella kingae

Choice of antibiotic:

IV Cefuroxime 50mg/kg (max. 1.5g) every 6 hours

Duration of therapy:

3 weeks for septic arthritis.

4-6 weeks in unifocal osteomyelitis.

At least 6 weeks in complex osteomyelitis.

(Unifocal disease indicates “simple” disease at a single site, whereas Complex disease includes any of the following: multifocal, significant bone destruction, resistant or unusual pathogen, immunosuppression.)

Notes:

*IV Clindamycin in penicillin allergy.

In unifocal disease consider IV to oral switch after 48 hours

In complex disease consider IV to oral switch after 14 days unless there is significant bone destruction as this often requires more than 6 weeks of IV antibiotics.

Considerations for IV to oral switch: clinical improvement, afebrile and oral fluids and medication can be established and CRP<20 or decreased by 66% of the highest value.

Oral antibiotic choice based on microbiology culture and sensitivity results, or if an organism has not been identified, use cefalexin as an oral stepdown and use the maximum dose allowed according to age/weight.

Birth - 3 months

Likely causative organism:

• Group B Streptococcus
• Staphylococcus aureus
• Kingella kingae

Choice of antibiotic:

IV Cefotaxime
+ IV Flucloxacillin*

Refer to BNFc and use maximum doses allowed according to age and weight.

Duration of therapy:

4 - 6 weeks

(Unifocal disease indicates “simple” disease at a single site, whereas Complex disease includes any of the following: multifocal, significant bone destruction, resistant or unusual pathogen, immunosuppression.)

Notes:

* IV Clindamycin in penicillin allergy.

Consider IV to oral switch after 14 days in unifocal disease and after 21 days in complex disease.

Considerations for IV to oral switch: clinical improvement, afebrile and oral fluids and medication can be established and CRP<20 or decreased by 66% of the highest value.

Oral antibiotic choice based on microbiology culture and sensitivity results, or if an organism has not been identified, use cefalexin as an oral stepdown and use the maximum dose allowed according to age/weight.

Bacterial meningitis is a notifiable disease. The local Public Health England team should be informed by phone within 24 hours to co-ordinate chemoprophylaxis:

Contact details for PHE teams in other regions can be found at https://www.gov.uk/guidance/contacts-phe-health-protection-teams

THE FOLLOWING MUST BE DISCUSSED WITH PUBLIC HEALTH

1. Meningococcal Infection:

Immediate family contacts should be given one of the following as soon as practical (ideally within 24 hours of diagnosis of the index case):

1. Oral ciprofloxacin as a single dose (unlicensed indication) Ciprofloxacin is the first line choice in all age groups and pregnancy. If ciprofloxacin is not suitable due to known hypersensitivity (rare), consider rifampicin or IM ceftriaxone as suggested below.

   Ciprofloxacin dose by age:
   1 month to 5 years - 125mg as a single dose
   5 years to 12 years - 250mg as a single dose
   12 years and over - 500mg as a single dose
   

   If necessary, ciprofloxacin tablets can be crushed and mixed with a small amount of food such as honey or jam (but not dairy products such as milk and yoghurt) and the full amount swallowed straight away. If ciprofloxacin liquid is required (e.g. children under 6 months who have not yet been weaned), this can be supplied from pharmacy in normal opening hours.

2. Oral rifampicin for 2 days (consult BNF for dose) If rifampicin is not suitable or can not be tolerated (may stain contact lenses, and interacts with many drugs including the contraceptive pill and antiepileptics), consider:
3. Intramuscular ceftriaxone as a single dose (unlicensed indication, consult BNF for dose)

In addition, consider use of Meningitis C vaccine in those close contacts not previously immunised (arranged via GP by PHE team).

2. Haemophilus influenzae Type b Infection

All immediate family contacts should be given oral Rifampicin for 4 days (Refer to the BNF for an adult dosage and the BNFc for a paediatric dosage):

• Any unvaccinated child contact aged 12-48 months should be given one dose of the Hib vaccine (arranged via GP by PHE team)
• Any unvaccinated child contact aged 2-11 months should be given three doses of the Hib vaccine (arranged via GP by PHE team)
3. Pneumococcal Meningitis

Chemoprophylaxis is not normally indicated for close contacts.

4. Other types of Bacterial Meningitis

Secondary prevention is not required.

References: NICE Guidelines: Bacterial meningitis and meningococcal septicaemia. September 2010. Guidance for public health management of meningococcal disease in the UK. Health Protection Agency. Februaruy 2011.

Approved by DTC: 31st March 2006 (v1) Minor revisions made: 5th June 2006 (v1). Further revisions approved by DTC/ MMC: 2nd May 2008 (v2)aa, 10th September 2010 (v3), 15th June 2011 (v4). Author(s): A Riordan, A Aindow, G Jones. Review date: June 2014

Dexamethasone should be given if strong evidence of bacterial meningitis. NICE guidance defines this as:

• frankly purulent CSF
• CSF white blood cell count greater than 1000/μL
• raised CSF white blood cell count with protein concentration greater than 1 g/L
• bacteria on Gram stain

The first dose should be given immediately before, or with the first dose of antibiotics in patients with meningitis with no rash (to exclude those with meningococcal disease).

If dexamethasone was not given before, or with the first dose of antibiotics, but was indicated as described above, try to ensure that the first dose of dexamethasone is given within 4 hours of starting antibiotics, but do not start dexamethasone more than 12 hours after starting antibiotics.

Do not start dexamethasone more than 12 hours after starting antibiotics.

Do not use steroids in children < 1 month old.

Do not use steroids if tuberculosis is suspected.

After the first dose of dexamethasone, discuss the need to continue steroid treatment with a consultant (a longer duration increases the risk of side effects, especially gastrointestinal haemorrhage).

Dosage:

Dexamethasone phosphate IV 0.15 mg/kg/dose given four times a day for 2-4 days

References: NICE Guidelines: Bacterial meningitis and meningococcal septicaemia. September 2010. Guidance for public health management of meningococcal disease in the UK. Health Protection Agency. Februaruy 2011.

> 1 month

Likely causative organism:

• Neisseria meningitidis
• Haemophilus influenzae
• Streptococcus pneumoniae

Choice of antibiotic:

IV Cefotaxime 50mg/kg (max 3g) every 6 hours

Add IV aciclovir only if seizures, focal neurological symptoms or known exposure to HSV infection. Continuation of aciclovir must be reviewed by a Consultant within 24 hours.

To ensure complete eradication from the nasopharynx, all patients with meningococcal disease should receive single dose of ciprofloxacin as soon as they are able to tolerate oral therapy.

Bacterial meningitis is a notifiable disease. The local Public Health England team should be informed by phone within 24 hours to co-ordinate chemoprophylaxis.

Duration of therapy:

Notes:

Contact the Infectious Diseases / Microbiology team if:

• patient has previous history of carriage or infection with antibiotic-resistant organisms
• causative organism cannot be identified
• patient has been overseas in the previous 3 months
• patient has had prolonged / multiple antibiotic use in the previous 3 months

Unless contraindicated, a lumbar puncture should be performed to confirm diagnosis of meningitis.

ROUTE OF ADMINISTRATION

Intravenous therapy is indicated due to severity of the condition and to ensure:

• penetration of CSF
• adequate concentration achieved

USE OF STEROIDS

See section in menu above.

RECOMMENDATIONS FOR PREVENTION OF SECONDARY CASES AMONG FAMILY CONTACTS

See section in menu above.

References: NICE Guidelines: Bacterial meningitis and meningococcal septicaemia. September 2010. Guidance for public health management of meningococcal disease in the UK. Health Protection Agency. Februaruy 2011.

Approved by Medicines Management Committee, May 2017

Birth - 1 month:

Likely causative organism:

• Group B Streptococcus
• Escherichia coli
• Listeria monocytogenes
• Neisseria meningitidis
• Haemophilus influenzae
• Streptococcus pneumoniae
• Herpes simplex virus
• Varicella zoster virus

Choice of antibiotic:

IV Cefotaxime + IV Amoxicillin*

*Stop amoxicillin once listeria meningitis is excluded.

Add IV aciclovir only if seizures, focal neurological symptoms or known exposure to HSV infection. Continuation of aciclovir must be reviewed by a Consultant within 24 hours.

To ensure complete eradication from the nasopharynx, all patients with meningococcal disease should receive single dose of ciprofloxacin as soon as they are able to tolerate oral therapy.

Bacterial meningitis is a notifiable disease. The local Public Health England team should be informed by phone within 24 hours to co-ordinate chemoprophylaxis.

Contact the Infectious Diseases team if:

• causative organism can not be identified
• patient has been overseas in the previous 3 months
• patient has had prolonged/multiple antibiotic use in the previous 3 months.

Duration of therapy:

Once causative organism is known (usually possible after 24 hours) therapy must be adjusted according to table below:

Notes:

Unless contraindicated, a lumbar puncture should be performed to confirm diagnosis of meningitis.

ROUTE OF ADMINISTRATION

Intravenous therapy is indicated due to severity of the condition and to ensure:

• penetration of CSF
• adequate concentration achieved

RECOMMENDATIONS FOR PREVENTION OF SECONDARY CASES AMONG FAMILY CONTACTS

See section in menu above.

References: NICE Guidelines: Bacterial meningitis and meningococcal septicaemia. September 2010. Guidance for public health management of meningococcal disease in the UK. Health Protection Agency. Februaruy 2011.

Approved by Medicines Management Committee, April 2017

Airway reconstruction (for example laryngotracheal or cricotracheal reconstructions).

Possible Patholgens:

• Staphylococcus aureus
• Streptococcus spp.
• Haemophilus influenzae
• Bacteroides spp.

Recommended antibiotics:

First line: IV co-amoxiclav

If patient is penicillin allergic:

IV clindamycin plus IV gentamicin.

If patient is colonised with Pseudomonas:

IV piperacillin / tazobactam.

Duration:

Ensure that enough doses are administered to provide 24 hours of antibiotic cover.

Notes:

Pseudomonas colonisation refers to colonisation of a tracheostomy or the respiratory tract.

Approved by DTC: 10th September 2010 (v1). Updated 19th August 2014 (v2). Author(s): A Riordan, D Sharpe. Reviewed: S Paulus, D Sharpe.

All ages

Note that Clostridium difficile in stool in children is often not the cause of their illness, other tests may be needed and treatment may not be indicated, refer to Infectious Diseases and / or Consultant Microbiologist for advice if C.difficile is suspected.

Likely causative organisms:

• Clostridium difficile

Choice of antibiotic:

Oral Metronidazole

Duration of therapy:

7-10 days

Notes:

Oral vancomycin may be used for patients who cannot tolerate or do not respond to metronidazole, but needs to be extemporaneously prepared by the pharmacy.

Relapse is common and should be treated in the same way as the initial episode; it is not believed to be due to antibiotic resistance.

Approved by Medicines Management Committee, May 2017

Birth - 3 months

Likely causative organisms:

• Enterobacteriaceae
• Streptococcus spp.

Choice of antibiotic:

IV Cefotaxime
+ IV Metronidazole

Duration of therapy:

5 days and assess response

Approved by Medicines Management Committee, May 2017

> 3 months

Likely causative organisms:

• Enterobacteriaceae
• Enterococcus spp.
• Streptococcus spp.
• Anaerobes
• Polymicrobial

Choice of antibiotic:

IV Piperacillin / tazobactam
In severe sepsis, consider adding a single dose of IV Gentamicin

Duration of therapy:

5 days and assess response

Notes:

Consider switching to oral co-amoxiclav when appropriate.

Use Ciprofloxacin plus Metronidazole as an alternative to piperacillin/tazobactam in penicillin allergy.

For Appendicitis, refer to the Appendicectomy Pathway

If there is a supply issue with IV ciprofloxacin, consider IV Cefuroxime as an alternative.

Approved by Medicines Management Committee, May 2017

All ages

Likely causative organisms:

• Polymicrobial

Choice of antibiotic:

IV Cefotaxime + IV Metronidazole
In severe sepsis, consider adding a single dose of IV Gentamicin.

Duration of therapy:

5 days and assess response

Approved by Medicines Management Committee, June 2018

Restricted antimicrobial policy

The use of the antimicrobials below should be restricted in order to minimise the development of antimicrobial resistance. Only Consultants from the specialties indicated can approve the use of the antimicrobials listed below and their recommendation must be documented in the case notes along with the following information:

1. Indication
2. Evidence of an assessment of severity (may include temperature, heart rate, respiratory rate, blood pressure, white cell count, CRP)
3. Evidence of appropriate cultures being taken (preferably before starting antimicrobials)

Pharmacy can dispense a 24 hour supply of the restricted antimicrobial until the appropriate approval can be granted to avoid a delay in starting treatment.

Oncology, respiratory, PICU, infectious diseases / microbiology:

Meropenem

Oncology, Infectious diseases / microbiology:

As above +
Liposomal Amphotericin, Voriconazole

Infectious diseases / microbiology only:

As above +
Caspofungin, IV Colistin, Daptomycin, Ertapenem, Fosfomycin, Levofloxacin, Linezolid, Micafungin, Meropenem, Temocillin, Tigecycline, Pivmecillinam

For dosing see full guideline

Approved May 2017

Antibiotics for surgical prophylaxis should be administered on induction.
If major blood loss (>25ml/kg) occurs during surgery an additional dose of prophylactic antibiotics should be considered after fluid replacement.
If surgery is prolonged additional dose(s) of cefuroxime 50mg/kg should be administered every 3 hours during surgery.
If teicoplanin and/or gentamicin are used ‐ do not re‐dose every 3 hours in prolonged surgery or give doses pre/post chest closure/exploration.

In the case of cephalosporin allergy use teicoplanin and gentamicin as an alternative to cefuroxime (see dose regime here). In the case of carriage of MRSA add teicoplanin to cefuroxime.

Cardiac surgery < 7 days old:

Likely pathogens

• Staphylococcus aureus

Recommended antibiotics:

IV Cefuroxime

Give 50 mg/kg at induction.
50 mg/kg/dose to be given every 12 hours (first PICU dose to be given 12 hours after last theatre dose)

Duration:

24 hours (2 doses) - unless chest open

Cardiac surgery > 7 days old:

Likely pathogens

• Staphylococcus aureus

Recommended antibiotics:

IV Cefuroxime

Give 50 mg/kg (max 1.5g) at induction.
50 mg/kg/dose to be given every 8 hours (first PICU dose to be given 8 hours after last theatre dose)

Duration:

24 hours (3 doses) - unless chest open

Notes:

If chest open (with or without ECMO) continue antibiotics until chest closure - refer to guidance for chest closure.

Approved May 2017

Chest closure or chest exploration on PICU:

Likely pathogens

• Staphylococcus aureus

Recommended antibiotics:

IV Cefuroxime

Give 50 mg/kg/dose (maximum 1.5g) 30 minutes prior to procedure (give only if cefuroxime dose administered > 3 hours previously).
Second dose of 50 mg/kg (maximum 1.5g) to be administered: 12 hours later if neonate 0-7 days or 8 hours later if > 7 days

Duration:

Dose pre and post procedure

Notes:

In the case of penicillin / cephalosporin allergy use IV teicoplanin plus IV gentamicin as an alternative to cefuroxime (see full guideline).

Approved by Medicines Management Committee, May 2017

The choice of oral antibiotic should account for factors potentially affecting adherence such as dosing frequency and palatability / taste of formulation. Palatable oral drugs in a sensible regimen (up to 3 times per day) should be used where possible, and middle of the night dosing of oral antibiotics should be avoided whenever possible, especially following discharge.

Oral liquids which should be avoided due to poor palatability include:

• Flucloxacillin oral liquid: consider using oral cephalexin liquid if patient cannot swallow flucloxacillin capsules.
• Clindamycin oral liquid: consider using an alternative (may need discuss suitable alternatives with pharmacy or Infectious Diseases / Microbiology)

Start Smart - Then Focus is a key Department of Health publication on best practice of antimicrobial prescribing. The key recommendations for antimicrobial treatment are summarised in the algorithm here.

General advice:

• Do not start antimicrobials in the absence of clinical evidence of bacterial infection, and document the indication for the antimicrobial on the prescription.
• Initiate prompt treatment with effective antimicrobials for severe or life-threatening infections as soon as possible and within one hour of presentation.
• Use antimicrobials with an adequate spectrum of cover for the likely pathogens for less severe infections.
• If the child is <1 month and the local guidelines do not give specific recommendations for this age group, treat as per Sepsis of Unknown origin guideline.
• Always use the optimal dosing regimen for the clinical indication and the patient’s individual parameters.
• Consider the risk of resistant pathogens (e.g. MRSA or ESBL-producing organisms) and offer alternative treatment regimens accordingly, or seek advice from Infectious Diseases / Microbiology.
• Confirm allergy status and offer alternative treatment choices for patients intolerant of recommended antimicrobial agents.
• Ensure that the appropriate specimens are taken for culture and sensitivity testing prior to commencing antibiotic treatment without causing delay to starting treatment in patients with severe sepsis or life-threatening infections.
• Consider intravenous (IV) administration only to patients who are severely ill, unable to tolerate oral treatment, or where oral therapy would not provide adequate coverage or tissue penetration.
• Consider switching IV antibiotics to the oral route of administration promptly according to local IV-to-oral switch guidance
• For infections listed as ‘H’ on Meditech microbiology report please see the High Dose Antibiotic Table
• Document the next review date or stop date on the prescription.
• It is essential to review antimicrobial prescriptions after 48-72 hours, and after a clinical review and checking microbiology results, a clear plan should be documented in the casenotes, which should be:
1. Stop
2. IV to oral Switch
3. Change antibiotic
4. Continue and review again in 72 hours or
5. Out-patient Parenteral Antibiotic Therapy (OPAT).

All ages

Likely causative organisms:

• Coagulase negative Staphylococcus

Choice of antibiotic:

INTRAVENTRICULAR vancomycin

(prepared doses available from pharmacy):

• Neonate: 10mg once every 24 hours
• Child 1 month-18 years: 10mg once every 24 hours

Duration of therapy:

10 days

Notes:

For all children, reduce to 5mg daily if ventricular size reduced or increase to 15-20mg once daily if ventricular size increased.

The use of intraventricular Gentamicin is not recommended.

All ages

Likely causative organisms:

• Coagulase negative Staphylococci
• Staphylococcus aureus
• Coliforms
• Streptococcus spp.
• Proprionibacterium acnes
• Corynebacterium spp.

Choice of antibiotic:

INTRAVENOUS Cefotaxime +
INTRAVENTRICULAR Vancomycin

Cefotaxime: refer to BNFc for neonatal doses. All other age groups should have 50mg/kg (max 3g) every 6 hours.

• Neonate: 10mg once every 24 hours
• Child 1 month-18 years: 10mg once every 24 hours

Duration of therapy:

10 days

Notes:

Remove shunt and replace with plain external ventricular drain (EVD).

For all children, reduce to 5mg daily if ventricular size reduced or increase to 15-20mg once daily if ventricular size increased.

The use of intraventricular Gentamicin is not recommended.

All ages

Likely causative organisms:

• Staphylococcus aureus

However, the predisposing injury influences the range of potential pathogens.

Choice of antibiotic:

INTRAVENOUS Cefuroxime +
INTRAVENOUS Metronidazole

Cefuroxime: 50mg/kg (max 1.5gram) every 8 hours. Metronidazole: refer to BNFc.

Duration of therapy:

Review at 5 days. Duration will depend on whether or not meningitis is present.

Debride scalp and skull but only remove superficial brain that is clearly non-viable. Remove readily accessible fragments/foreign bodies. Deeper fragments should not be sought if it means causing damage to the brain. Ensure watertight dural closure; use a periosteal graft or facia lata if needed. Care must be taken in potentially infected situations with artificial dura.

Approved by Medicines Management Committee, May 2017

All ages

Likely causative organisms:

• Streptococcus spp.
• Enterobacteriaceae
• Staphyloccoccus aureus

Choice of antibiotic:

INTRAVENOUS Cefotaxime +
INTRAVENOUS Metronidazole +
(INTRAVENOUS Vancomycin if post-trauma or post-op)

Cefotaxime and Metronidazole: refer to BNFc and use maximum dose allowed according to age and weight. Vancomycin: refer to local dosing and monitoring guidelines.

Duration of therapy:

Approx. 6 weeks. A longer duration may be required if the abscess has not been aspirated.

Can be converted to IV ceftriaxone once daily and oral metronidazole once the patient has improved (with view to OPAT).

Patient may be converted to oral after 2 weeks, if:

1. abscess drained,
2. good clinical response and
3. organism and sensitivities known.

Notes:

Insert central venous catheter / PICC line

All ages

Empirical therapy

Choice of antibiotic:

IV Cefotaxime + IV Vancomycin

Cefotaxime: refer to BNFc and use maximum dose allowed according to age and weight. Vancomycin: refer to local dosing and monitoring guidelines.

Duration of therapy:

2-3 weeks depending on clinical response

Notes:

Consult ID/Micro for optimal therapy choices and duration when causative organism is known

All ages

Likely causative organisms:

• Influenza A and B

Note: PHE provides information about the dominant circulating strain and the resistance risk. H1N1 should be considered high risk for resistance.

Treatment:

Treatment should be given to the following groups:

1. High risk patients including immunocompromised
2. Complicated cases of influenza

First line: Oseltamivir
Second line: Zanamivir (nebulised or IV)

Second line should be considered if the patient is immunocompromised with suspected or confirmed infection with a strain with high risk for resistence. NOTE: cannot be used in < 5 years.

Prophylaxis:

Patients in a high risk group should receive prophylaxis following contact with Influenza.

First line: Oseltamivir
Second line: Zanamivir

This should be considered in high risk patients with proven contact with Influenza with high resistance if the child is over 5 years. In patients with immunosuppresion and > 5 years, zanamivir should be considered in all cases of suspected contact with high resistance strain of influenza.

All ages

Likely causative organisms:

• Group A Streptococcus
• Viridans Streptococci
• Anaerobes

Choice of antibiotic:

Oral / IV Co-amoxiclav

Duration:

5 days

Notes:

If there is an obvious collection of pus this needs incision and drainage +/- extraction of causative tooth. Choice in penicillin allergy - Clarithromycin plus Metronidazole

All ages

Likely causative organisms:

• Staphylococcus aureus
• Streptococci
• Anaerobes

Choice of antibiotic:

Oral / IV Co-amoxiclav

Duration:

5 days

Notes:

Consider ultra sound scan to exclude collection of pus within infected gland. Any collection identified may need surgical drainage. Choice in penicillin allergy - Clarithromycin plus Metronidazole

Hello! You can navigate this app using the icons at the bottom of the screen.

Please note that where doses are often not specified to encourage use of the BNFc.

There are a number of guidelines / pathways (in PDF layout) that can viewed directly within the antimicrobial guide.

If you have any technical problems using this application please email support@youngrobot.com. We would value any feedback on your experience of this app / suggestions for development by emailing Andrew Taylor (Antimicrobial Pharmacist) on Andrew.Taylor@alderhey.nhs.uk.