CENTRAL NERVOUS SYSTEM / EYE

Often polymicrobial
S. milleri and other streptococci
Anaerobes
Gram-negatives 

3rd gen cephalosporin (high dose)⁴ and
Metronidazole 7.5 mg/kg (500 mg) IV 8H

3 weeks minimum
Penicillin hypersensitivity or risk of MRSA³: add Vancomycin 15 mg/kg (max 750 mg) IV 6H

Post-neurosurgery

As above plus

S. aureus
S. epidermidis

As above add Vancomycin 15 mg/kg (750 mg) IV 6H

Uncomplicated 10 days minimum
Complicated 3 weeks minimum

Herpes simplex virus
Enteroviruses
Arboviruses
M. pneumoniae

Aciclovir 20 mg/kg IV 12H ( <30 weeks gestation), 8H (>30 weeks gestation to  <3 months corrected age)
500 mg/m² IV 8H (3 months – 12 years)
10 mg/kg IV 8H (>12 years)

3 weeks minimum
Consider adding Azithromycin if M. pneumoniae suspected

Over 2 months of age 

S. pneumoniae⁵
N. meningitidis
H. influenzae type b⁶

3rd gen cephalosporin (high dose)⁴ 

S. pneumoniae 10 days
N. meningitidis 5–7 days
H. influenzae type b 7–10 days
Consider addition of Dexamethasone 0.15 mg/kg (max 10 mg) IV 6H for 4 days

Over 2 months of age and possibility of penicillin-resistant pneumococci⁵

As above

3rd gen cephalosporin (high dose)⁴ and
Vancomycin 15 mg/kg (750 mg) IV 6H

Under 2 months of age

As above plus
Group B streptococci
E. coli and other Gram-negative coliforms
L. monocytogenes

Benzylpenicillin 60 mg/kg (2.4 g) IV
12H (week 1 of life)
6H (week 2–4 of life)
4H (>week 4 of life) and

3rd gen cephalosporin (high dose)⁴

Gram-negative 3 weeks
GBS/Listeria 2–3 weeks
Substitute Benzylpenicillin with Vancomycin if possibility of penicillin-resistant pneumococci⁵

With shunt infection, post-neurosurgery, head trauma or CSF leak

As for over 2 months of age plus S. epidermidis
S. aureus
Gram-negative coliforms incl. P. aeruginosa

Vancomycin 15 mg/kg (750 mg) IV 6H and
Ceftazidime 50 mg/kg (2 g) IV 8H

10 days minimum

Contact prophylaxis

N. meningitidis

Ciprofloxacin 250 mg (5–12 years) 500 mg (≥12 years) oral single dose
Unable to take tablets: Rifampicin 5 mg/kg ( <1 month) or 10 mg/kg (≥1 month) (max 600 mg) oral bd for 2 days

2 days

Contact prophylaxis

H. influenzae type b

Rifampicin 20 mg/kg (600 mg) oral daily

4 days

S. aureus
H. influenzae spp.
S. pneumoniae
M. catarrhalis
Gram-negatives
Anaerobes

3rd gen cephalosporin (high dose)⁴

IV duration based on severity and improvement (usually 3-4 days)
Switch to Amoxicillin/clavulanate (400/57 mg per 5 mL) 22.5 mg/kg (max 875 mg) (Amoxicillin component) = 0.3 mL/kg (max 11 mL) oral bd
10 days minimum total duration
Consider adding Metronidazole if not responding

Mild

Group A streptococci
S. aureus
H. influenzae spp.

Cefalexin 20 mg/kg (750 mg) oral tds

7–10 days

Bilateral findings and/or painless or non-tender swelling in a well looking child is more likely to be an allergic reaction

Moderate

Cefazolin 50 mg/kg (2 g) IV 8H or
Ceftriaxone 50 mg/kg (2 g) IV daily (for hospital-in-the-home)

Severe, or not responding, or under 5 years of age and non-Hib immunised

As above plus
H. influenzae type b⁶

3rd gen cephalosporin (high dose)⁴

IV duration based on severity and improvement (usually 3-4 days)
10 days minimum total duration

CARDIOVASCULAR

Native valve or homograft 

Viridans streptococci
Other streptococci
Enterococcus spp.
S. aureus

Benzylpenicillin 60 mg/kg (2.4 g) IV 6H and
Flucloxacillin 50 mg/kg (2 g) IV 4H and
Gentamicin

Birth - 1 month: 5 mg/kg IV daily

<10 years: 7.5 mg/kg (320 mg) IV daily

≥10 years: 6 mg/kg (560 mg) IV daily 

4–6 weeks
Gentamicin 1 mg/kg (max 80 mg) IV 8H for 1–2 weeks when used only for synergy
(Gentamicin monitoring is generally not required with low dose in this setting)

Artificial valve, post-surgery or suspected MRSA³ 

As above plus
S. epidermidis

Vancomycin 15 mg/kg (750 mg) IV 6H and
Flucloxacillin 50 mg/kg (2 g) IV 4H and

Gentamicin

Birth - 1 month: 5 mg/kg IV daily

<10 years:         7.5 mg/kg (320 mg) IV daily

≥10 years:         6 mg/kg (560 mg) IV daily 

For dental procedures only 

Viridans streptococci
S. aureus
S. pneumoniae
Other Gram-positive cocci Enterococcus spp.

Amoxicillin 50 mg/kg (2 g)
Local anaesthetic: give orally 1 hour before procedure
General anaesthetic: give IV with induction

Penicillin hypersensitivity: substitute Amoxicillin with Cefalexin 50 mg/kg (max 2 g) oral
Immediate or severe penicillin hypersensitivity: substitute with Clindamycin 20 mg/kg (max 600 mg) oral or IV

GASTROINTESTINAL

Salmonella spp.

3rd gen cephalosporin⁴

5–7 days
Antibiotic treatment is generally unnecessary for most other organisms
Consider adding Azithromycin in returned travellers from regions with high prevalence of cephalosporin resistance

Antibiotic-associated

C. difficile

Metronidazole 7.5 mg/kg (400 mg) oral tds

7–10 days

G. lamblia

Metronidazole 30 mg/kg (2 g) oral daily

3 days 

Intra-abdominal infection

Appendicitis, not septic

Gram-negative coliform

Anaerobes

Enterococcus spp.      

Appendicitis antibiotic regimen and durations (Prompt)

Uncomplicated appendicitis, including non-perforated gangrenous appendicitis: stop immediately post appendicectomy

Complicated appendicitis including perforation, peri-appendicular abscess peritonitis): total duration (IV + oral) after adequate surgical source control is 4 days

Ampicillin or Amoxicillin 50 mg/kg (2 g) IV 6H

and
Gentamicin

Birth - 1 month: 5 mg/kg IV daily

<10 years:         7.5 mg/kg (320 mg) IV daily

≥10 years:         6 mg/kg (560 mg) IV daily

and
Metronidazole 7.5 mg/kg (500 mg) IV 8H

See footnote 7 re Gentamicin dosing/monitoring

Child who has undergone biliary drainage: 4 days after drainage (IV + oral)
IV to oral switch: Amoxicillin+clavulanate 22.5+3.2 mg/kg up to 875+125 mg oral 12H.  For children who have not undergone biliary drainage, use 8-hourly dosing

Enterobius vermicularis

Mebendazole 50 mg oral (<10 kg) 100 mg oral (≥10 kg)
or
Pyrantel 10 mg/kg (1 g) oral

Single dose; may need to repeat after 14 days
Treat whole family

GENITOURINARY

Over 3 months of age and not sick 

E. coli
P. mirabilis
K. oxytoca
Other Gram-negatives

Cefalexin 20 mg/kg (750 mg) oral tds
or
Trimethoprim 4 mg/kg (150 mg) oral bd
or
Trimethoprim/Sulfamethoxazole (8/40 mg/mL) 0.5 mL/kg (20 mL) oral bd

5 days

Under 3 months of age or sick or acute pyelonephritis

Gentamicin

Birth - 1 month: 5 mg/kg IV daily

<10 years:         7.5 mg/kg (320 mg) IV daily

≥10 years:         6 mg/kg (560 mg) IV daily

5–7 days for UTI
7–10 days for pyelonephritis.

Consider early switch to Cefalexin:

<12 months: 25 mg/kg (max 1 g) oral qid

≥12 months: 45 mg/kg (max 1.5 g) oral tds

See footnote 6 re Gentamicin dosing/monitoring

As above

Trimethoprim 2 mg/kg (150 mg) oral daily
or
Trimethoprim/Sulfamethoxazole (8/40 mg/mL) 0.25 mL/kg (10 mL) oral daily

Routine prophylaxis is not recommended

RESPIRATORY

H. influenzae type b⁶

Ceftriaxone 50 mg/kg (1 g) IV daily

5 days
Consider addition of Dexamethasone

In immunocompromised 

 In immunocompetent (only if within 72 hours of onset with severe pain and dehydration)

Herpes simplex virus

Aciclovir 500 mg/m² IV 8H (3 months–12 years) 10 mg/kg IV 8H (>12 years)

Consider Aciclovir 10 mg/kg (400 mg) oral five times daily

7 days

Until no new lesions
Newer

Influenza A, B

Oseltamivir
3 mg/kg oral bd (Birth – 12 months)
30 mg oral bd (>12 months and <15 kg)
45 mg oral bd (15-23 kg)
60 mg oral bd (23-40 kg)
75 mg oral bd (>40 kg)

5 days

Acute diffuse 

S. aureus
S. epidermidis
P. aeruginosa
Proteus spp.
Klebsiella spp.

Topical steroid/antibiotic drops

7 days
Clean ear canal
(± insertion of wick soaked in drops if ear canal oedematous)

Acute localised (furuncle) ± cellulitis

S. aureus
Group A streptococci

As for cellulitis

5 days

Failure of first-line treatment, high fever or severe persistent pain

As above plus
P. aeruginosa

Piperacillin/Tazobactam 100 mg/kg (4 g) (Piperacillin component) IV 8H

14 days minimum
Consider fungal infection

Viruses
S. pneumoniae
M. catarrhalis
H. influenzae spp.
Group A streptococci

Consider no antibiotics for 48 hours if over 6 months of age
If treatment indicated
Amoxicillin 30 mg/kg (1 g) oral bd

5 days
Treatment indicated if infection in one hearing ear or associated with cochlear implant

B. pertussis

Azithromycin 10 mg/kg (500 mg) oral daily (Birth – 6 months), 10 mg/kg oral on Day 1, then 5 mg/kg (250 mg) daily (≥6 months)

5 days

Can be given up to 3 weeks after contact with index case or if symptoms <3 weeks

Mild (outpatient) 

Viruses
S. pneumoniae
H. influenzae spp.

Amoxicillin 30 mg/kg (1 g) oral tds

3-5 days

Moderate (inpatient)

As above

Amoxicillin 30 mg/kg (1 g) oral tds

5 days
Consider Benzylpenicillin 60 mg/kg (max 2.4 g) IV 6 H if unable to tolerate oral intake or vomiting

Severe (≥2 of: severe respiratory distress, severe hypoxaemia or cyanosis, marked tachycardia, altered mental state OR empyema ie requiring ICU care)

As above plus
S. aureus
Group A streptococci
Gram-negatives

3rd gen cephalosporin⁴

10 days minimum²
Consider adding Azithromycin 10 mg/kg (max 500 mg) IV daily to cover M. pneumoniae and other atypical pathogens and Oseltamivir to cover influenza virus

Viruses
Group A streptococci (GAS)

Features of GAS infection in child ≥4 years AND high-risk group or suppurative complications:
Phenoxymethylpenicillin (Penicillin V) 250 mg oral bd (<20 kg) 500 mg oral bd (≥20 kg)
or
Benzathine benzylpenicillin 450mg (600 000 units) IM ( <20 kg), 900 mg (1.2 million units) IM (>20 kg) as a single dose

10 days oral treatment
High-risk groups:

• Indigenous Australians
• Maori and Pacific Islander
• Personal history of rheumatic fever or rheumatic heart disease
• Family history of rheumatic fever or rheumatic heart disease
• Immunosuppressed

Benzylpenicillin  60 mg/kg (2.4 g) IV 6H

Continue IV therapy for 1-2 days following successful abscess drainage, then switch to oral therapy for total duration of 10 days

Amoxicillin/Clavulanate
25 mg/kg (1 g) (Amoxicillin component) IV 8H (≥3 months and ≥4 kg)

10-14 days

SKIN/SOFT TISSUE/BONE

Viridans streptococci
S. aureus
Group A streptococci
Oral anaerobes
E. corrodens
Pasteurella spp. (cat and dog)
C. canimorsus (dog)

Amoxicillin/Clavulanate (400/57 mg/5 mL) 22.5 mg/kg (875 mg) (Amoxicillin component) 0.3 mL/kg (11 mL) oral bd

5 days
Treat established infection
Prophylaxis generally not required, except:

• Presentation delayed >8 hours
• Puncture wound unable to be adequately debrided
• Bite on hands, feet, face
• Bite involves deep tissues (e.g. bones, joints, tendons)
• Bite involves an open fracture
• Immunocompromised patient
• Cat bites

Check tetanus immunisation status

If severe, penetrating injuries, esp. involving joints or tendons

As above

Amoxicillin/Clavulanate
25 mg/kg (1 g) (Amoxicillin component) IV 12H (Birth – 3 months or <4 kg), 8H (≥3 months and ≥4 kg)

14 days
Increase to 6H in severe infections (≥3 months and ≥4 kg)

Mild/moderate (outpatient)

Group A streptococci
S. aureus

Cefalexin 20 mg/kg (750 mg) oral tds

5–10 days

If rapidly progressive consider adding Clindamycin 15 mg/kg (max 600 mg) IV 8H

Moderate/severe (inpatient)

Cefazolin 50 mg/kg (2 g) IV 8H
or
Ceftriaxone 50 mg/kg (2 g) IV daily (for hospital-in-the-home)

Facial cellulitis in child under 5 years of age and non-Hib immunised

As above plus
S. pneumoniae
H. influenzae spp.⁶

3rd gen cephalosporin⁴

Necrotising fasciitis

As above

Vancomycin 15 mg/kg (750 mg) IV 6H and
Meropenem 20 mg/kg (1 g) IV 8H and
Clindamycin 15 mg/kg (600 mg) IV 8H

Consider IVIg

Often polymicrobial
Viridans and anginosus group streptococci
Oral anaerobes
S. aureus

Amoxicillin 25 mg/kg (500 mg) oral tds or Benzylpenicillin 60 mg/kg (2.4 g) IV 6H

7 days
Dental/surgical management required

Pediculus humanus var. capitis

Dimeticone 4% lotion

Repeat after one week

Group A streptococci
S. aureus

Mupirocin 2% ointment top tds if localised
or
Cefalexin 20 mg/kg (750 mg) oral tds 

5 days

S. aureus
Group A streptococci
Oral anaerobes

Cefalexin 20 mg/kg (750 mg) oral tds

7 days

Severe

As above

Cefazolin 50 mg/kg (2 g) IV 8H

May require longer than 7 days

Uncomplicated 

S. aureus
Group A streptococci

Kingella kingae (partic ≤4y)
S. pneumoniae

Cefazolin 50 mg/kg (2 g) IV 8H 

Switch to oral Cefalexin 45 mg/kg (max 1.5 g) oral tds once afebrile plus clinical improvement plus inflammatory markers decreasing
3 weeks for uncomplicated cases²

If under 5 years of age and non-Hib immunised

As above
plus H. influenzae type b⁶

3rd gen cephalosporin⁴

In patient with sickle cell anaemia

As above
plus Salmonella spp.

3rd gen cephalosporin⁴

3 weeks minimum

With penetrating foot injury

As above
plus P. aeruginosa

Piperacillin/Tazobactam 100 mg/kg (4 g) (Piperacillin component) IV 6H

Surgical intervention important

Consider tetanus vaccine

Sarcoptes scabiei

Permethrin 5% cream top

One application from neck down; leave on for minimum of 8H (usually overnight)
May need to repeat after 7 days
Treat whole family

Consider Ivermectin as alternative to topical therapy: 200 micrograms/kg oral with fatty food. Repeat treatment in 7 days

As for osteomyelitis

As for osteomyelitis

3 weeks for uncomplicated cases²
Always consider surgical drainage

In immunocompromised or neonate 

Shingles
In immunocompromised

Involving eye

Varicella zoster virus

Aciclovir 20 mg/kg IV 12H ( <30 weeks gestation), 8H (>30 weeks gestation – <3 mths corrected age)
500 mg/m² IV 8H (3 months – 12 years),  10 mg/kg IV 8H (>12 years)

Oral treatment (above) and Aciclovir ointment to eye 5 times per day

7 days
Consider zoster immunoglobulin for neonates or immunocompromised exposed to chickenpox

Shingles in immunocompetent children does not generally require treatment

SEPSIS (UNDER 2 MONTHS OF AGE)

Community-acquired infection 

Group B streptococci
E. coli and other Gram-negative coliforms
L. monocytogenes
H. influenzae spp.⁶ plus those listed below for 'Septicaemia with unknown CSF'

Benzylpenicillin 60 mg/kg IV
12H (week 1 of life)
6H (week 2–4 of life)
4H (>week 4 of life) and
3rd gen cephalosporin⁴

Duration depends on culture results
Premature neonates require special dosing consideration
Also consider disseminated HSV infection, particularly under 2 weeks of age

If abdominal source suspected

As above
plus Anaerobes

Amoxicillin or Ampicillin 50 mg/kg (2 g) IV 6H

and
Gentamicin

Birth - 1 month: 5 mg/kg IV daily

1-2 months:       7.5 mg/kg (320 mg) IV daily 

and
Metronidazole 15 mg/kg IV stat, then 7.5 mg/kg IV 8H

SEPSIS (OVER 2 MONTHS OF AGE)

Sepsis with unknown CSF

Meningitis not excluded

S. pneumoniae⁵
N. meningitidis
S. aureus
Group A streptococci
Gram-negatives

3rd gen cephalosporin (high dose)⁴

Duration depends on culture results

If central line in situ (non-oncology) or suspected MRSA infection

As above
plus S. epidermidis

Add Vancomycin 15 mg/kg (750 mg) IV 6H

Sepsis with normal CSF

Meningitis excluded: clinically (and LP therefore not performed) or normal CSF 

As above

Cefazolin 50 mg/kg (2 g) IV 8H and

Gentamicin

Birth - 1 month: 5 mg/kg IV daily

<10 years:         7.5 mg/kg (320 mg) IV daily

≥10 years:         6 mg/kg (560 mg) IV daily 

Duration depends on culture results

In non-Hib immunised

As above plus
H. influenzae type b⁶

3rd gen cephalosporin⁴ 

As above plus
Enterococcus spp.
P. aeruginosa

Piperacillin/Tazobactam 100 mg/kg (4 g) (Piperacillin component) IV 6H (8H if <6 months)

If systemic compromise or high-risk cancer treatment or inpatient onset of symptoms
add Amikacin 22.5 mg/kg (1.5 g) IV daily (<10 years) 18 mg/kg (1.5 g) IV daily (≥10 years)

Local protocols for fever and neutropenia may differ

Target trough (<2 mg/L pre 3rd dose)

If suspected C. difficile colitis add Metronidazole 7.5 mg/kg IV/oral 8H

As above plus Gram-positive cocci incl. S. epidermidis

Piperacillin/Tazobactam as above and
Amikacin as above and
Vancomycin 15 mg/kg (750 mg) IV 6H

Toxic shock syndrome

S. aureus
Group A streptococci

3rd gen cephalosporin (high dose)⁴ and

Vancomycin 15 mg/kg (750 mg) IV 6H and

Clindamycin 15 mg/kg (600 mg) IV 8H and

Intravenous immunoglobulin 2 g/kg IV

GAS contact prophylaxis: Cefalexin 25 mg/kg (max 1 g) oral bd for 10 days