Paediatric Antibiotic Prescribing

Antibiotics in children are chosen by the likely organism, site of infection, age, severity and local resistance, with samples taken before the first dose whenever this does not delay treatment in a sick child. Most coughs, colds, sore throats and acute diarrhoea are viral and do not need antibiotics.

Principles. Use the narrowest effective agent, the right dose by weight, the shortest effective course, an early intravenous to oral switch, and a review at 48 to 72 hours with culture results.

• Early-onset neonatal sepsis: amoxicillin or ampicillin 50 mg/kg intravenously every 12 hours in the first 7 days (every 8 hours from day 8) plus gentamicin 4 to 5 mg/kg once daily. Treat 7 to 10 days for bacteraemia and 14 to 21 days for meningitis.
• Pneumonia, non-severe: amoxicillin 40 to 45 mg/kg orally every 12 hours (maximum 3 g/day) for 3 to 5 days.
• Pneumonia, severe: ampicillin 50 mg/kg intravenously every 6 hours plus gentamicin 5 to 7.5 mg/kg intravenously once daily (the dose range depends on region and product); change to oral amoxicillin after 48 hours of improvement.
• Bacterial meningitis beyond the neonatal period: ceftriaxone 50 mg/kg intravenously every 12 hours or 100 mg/kg once daily (maximum 4 g/day) for 7 to 10 days.
• Acute otitis media: amoxicillin 40 mg/kg orally every 12 hours for 5 days (7 to 10 days under 2 years or if severe).
• Streptococcal pharyngitis or rheumatic fever prophylaxis: benzathine benzylpenicillin single intramuscular dose, 600,000 units under 27 kg and 1.2 million units for 27 kg or more.
• Severe infection with sepsis: ceftriaxone 50 to 80 mg/kg intravenously once daily (maximum 4 g/day), with a cause-specific change after cultures.
• Urinary tract infection: choose by urine culture and local resistance, oral for 3 to 5 days in lower tract disease and 7 to 10 days in upper tract disease, with intravenous therapy if septic or unable to take oral.

Avoid or restrict. Tetracyclines under 8 years (except doxycycline for severe indications), fluoroquinolones, chloramphenicol in neonates, cotrimoxazole under 6 weeks (except prophylaxis in HIV-exposed infants), and ceftriaxone with calcium infusions or jaundice in neonates.

Kidney impairment. Extend the interval for aminoglycosides, vancomycin, penicillins at high dose and cephalosporins when creatinine clearance falls under 30 mL/min/1.73 m2, and use a drug level where available.

Liver impairment. Avoid ceftriaxone in combined hepatic and biliary disease, and review macrolides and rifampicin.

Severe malnutrition. Give broad-spectrum antibiotics routinely and reduce aminoglycoside doses for kidney risk.

Special groups. Breastfed infants of mothers on antibiotics need review for diarrhoea and thrush. Adolescents who are pregnant need teratogenic drugs avoided (tetracyclines, fluoroquinolones). In East Africa, penicillin resistance is lower than gram-negative resistance, so local sepsis patterns decide empirical choices.

Monitoring. Reassess clinically at 48 to 72 hours, with temperature, feeding, respiratory rate and cultures. Measure gentamicin pre-dose level (under 1 mg/L) and vancomycin trough or area under the curve. Check creatinine and sodium on prolonged aminoglycoside or cephalosporin therapy.

Referral and escalation. Escalate for no improvement at 48 hours, rising inflammatory markers, suspected resistant organisms, central nervous system infection, bone and joint infection, and endocarditis.

Stopping. Stop at the planned duration. Stop empirical antibiotics at 48 hours when cultures are negative and the child is well. Avoid prolonged courses without a source.