Fast Facts: Pediatric Antibiotics

Acute Bacterial Conjunctivitis 

 Acute Bacterial Rhinosinusitis (Sinus Infection) 

 Acute Lymphadenitis (Swollen Lymph Nodes) 

 Acute Otitis Media (AOM) 

 Animal Bites 

 Atypical Pneumonia (Walking Pneumonia) 

 Cellulitis 

 Conjunctivitis (Pink Eye) 

 Cystitis (Bladder Infection, Uncomplicated UTI) 

 Dental Abscess 

 Group A Streptococcal Pharyngitis (Strep Throat) 

 Human Bites 

 Impetigo 

 Otitis Externa (Swimmer’s Ear) 

 Otorrhea (Ear Discharge) 

 Pertussis (Whooping Cough) 

 Pneumonia 

 Pyelonephritis (Kidney Infection, Febrile UTI) 

 Sinus Infection (Acute Bacterial Rhinosinusitis) 

 Strep Throat (Group A Streptococcal Pharyngitis) 

 Swimmer’s Ear (Otitis Externa) 

 Walking Pneumonia (Atypical Pneumonia) 

 Whooping Cough (Pertussis) 

 

 ACUTE OTITIS MEDIA (AOM) 

 

 Watchful waiting (WW) / Safety-Net Antibiotic Prescription (SNAP): 

 

 Joint decision between provider and caregiver 

 Must have close follow-up (within 48–72 hours) if SNAP not given 

 Must be able to fill antibiotic prescription if signs/symptoms worsen or fail to improve in 48–72 hours from onset 

 Note: If using WW/SNAP, place a comment in prescription instructions: “ Fill only upon patient/family request ” 

 

 

 Antibiotic Recommendations 

 

 Duration: 

 

 <2 years or severe disease: 10 days 

 2–5 years: 7 days 

 ≥6 years: 5 days 

 Recent data suggests 5 days may be sufficient for children >2 years with AOM of any severity

 

 (Frost et al. J Pediatr. 2020 May; 220:109-115.e1). 

 

 

 

 

 First-line therapy: 

 

 Amoxicillin 40–50 mg/kg/dose BID (max 2000 mg/dose) 

 

 

 If received amoxicillin within the past 30 days, in daycare, or with concomitant conjunctivitis: 

 

 Amoxicillin/clavulanate 40–50 mg/kg/dose (amoxicillin component) PO BID (max 2000 mg amoxicillin/dose) 

 

 

 Penicillin Allergy: 

 

 Mild/Moderate—Rashes, including hives: 

 

 Cefuroxime: 250 mg PO BID (tablets only, not crushable) 

 Cefdinir: 7 mg/kg/dose PO BID (max 300 mg/dose) 

 Cefpodoxime: 5 mg/kg/dose PO BID (max 200 mg/dose) 

 Cefprozil: 15 mg/kg/dose PO BID (max 500 mg/dose) 

 Ceftriaxone: 50 mg/kg/dose IM/IV qDay x 1–3 days (max 1000 mg/dose) 

 

 

 Severe—Anaphylaxis: 

 

 Clindamycin 10 mg/kg/dose PO TID (max 600 mg/dose) 

 

 

 

 

 Failure to improve after 48–72 hours of initial antibiotic therapy: 

 

 Treatment failure with amoxicillin: 

 

 Amoxicillin/clavulanate 40–50 mg/kg/dose (amoxicillin component) PO BID (max 2000 mg amoxicillin/dose) 

 

 

 Treatment failure with amoxicillin/clavulanate: 

 

 Ceftriaxone 50 mg/kg/dose (max 1000 mg/dose) IM or IV daily x 3 days 

 Clindamycin 10 mg/kg/dose PO TID (max 600 mg/dose) PLUS: 

 

 Cefuroxime 250 mg PO BID 

 Cefpodoxime 5 mg/kg/dose PO BID (max 200 mg/dose) 

 

 

 

 

 

 

 

 

 

 

 OTORRHEA / OTITIS EXTERNA 

 

 Perforated Tympanic Membrane (+ Oral Antibiotics) OR AOM with Tubes: 

 

 Ciprodex (ciprofloxacin/dexamethasone): 4 drops BID x 7 days for patients >6 months. 

 Alternative (if Ciprodex is unavailable or cost-prohibitive): 

 

 Ciprofloxacin ophthalmic solution: 2 drops +/- dexamethasone ophthalmic solution: 2 drops BID x 7 days for patients >6 months. 

 

 

 Ofloxacin otic solution: 5 drops BID x 10 days for patients >6 months. 

 

 

 Intact Tympanic Membrane (Non-complicated Otitis Externa): 

 

 Ciprodex (ciprofloxacin/dexamethasone): 4 drops BID x 7 days. 

 Ofloxacin otic solution: 5 drops BID x 10 days. 

 Cortisporin otic solution: 3 drops TID x 7 days. 

 

 

 Additional Considerations: 

 

 Ear wick placement may help deliver medication to the site of infection, especially in cases of significant canal swelling. 

 Pain management (e.g., acetaminophen or ibuprofen) is critical for patient comfort. 

 

 

 Notes: 

 

 Ensure proper administration technique to maximize effectiveness (e.g., warming drops before application and keeping the ear tilted for several minutes post-application). 

 If symptoms persist or worsen after 48–72 hours, reassess for alternative diagnoses or complications. 

 

 

 

 

 GROUP A STREPTOCOCCAL PHARYNGITIS 

 

 First-line therapy: 

 

 Amoxicillin: 50 mg/kg/dose PO BID (max 1000 mg/day) x 10 days 

 Bicillin L-A (Penicillin G benzathine): IM 

 

 <27 kg: 600,000 U x 1 dose 

 ≥27 kg: 1.2 million U x 1 dose 

 

 

 Penicillin VK: PO 

 

 <27 kg: 250 mg BID-TID x 10 days 

 ≥27 kg: 500 mg BID-TID x 10 days 

 

 

 

 

 Penicillin Allergy: 

 

 Mild—Rashes, including hives: 

 

 Cephalexin: 20–25 mg/kg/dose PO BID (max 500 mg/dose) x 10 days 

 

 

 Severe—Anaphylaxis: 

 

 Clindamycin: 7 mg/kg/dose PO TID (max 300 mg/dose) x 10 days 

 Azithromycin: 12 mg/kg/dose PO qDay (max 500 mg/dose) x 5 days 

 

 

 

 

 Notes: 

 

 Azithromycin is not recommended unless the patient has a severe allergy to both penicillins and cephalosporins. Resistance is well-known, and treatment failure may occur. 

 

 

 

 

 UNCOMPLICATED PNEUMONIA 

 

 Duration: 

 

 5 days 

 Note: Shorter duration of 3–5 days may be sufficient for patients >6 months old (Kuitunen et al. Clin Infect Dis. 2023 Feb 8;76(3):e1123-e1128). 

 

 

 First-line therapy: 

 

 Amoxicillin: 40–50 mg/kg/dose PO BID (max 2000 mg/dose) 

 Note: Amoxicillin/clavulanate provides no additional coverage for Streptococcus pneumoniae and is not recommended as a first-line agent. 

 

 

 Penicillin Allergy: 

 

 Mild/Moderate—Rashes, including hives: 

 

 Cefuroxime: 250–500 mg PO BID (for children able to swallow pills; only available in tablets) 

 Cefpodoxime: 5 mg/kg/dose PO BID (max 200 mg/dose) 

 Cefprozil: 15 mg/kg/dose PO BID (max 500 mg/dose) 

 

 

 Note: Cefdinir is NOT recommended for empiric treatment of community-acquired pneumonia due to reduced effectiveness against Streptococcus pneumoniae . Clindamycin is preferred if above options are unavailable. 

 Severe—Anaphylaxis ± Cephalosporin Allergy: 

 

 Clindamycin: 10 mg/kg/dose PO TID (max 600 mg/dose) 

 

 

 Severe—Anaphylaxis + Cephalosporin Allergy + Intolerance of Clindamycin: 

 

 Levofloxacin: 

 

 Ages 6 months–5 years: 8–10 mg/kg/dose PO BID 

 ≥5 years: 16–20 mg/kg/dose PO QD (max 750 mg/day) 

 

 

 

 

 

 

 

 

 ATYPICAL PNEUMONIA 

 

 Duration: 

 

 5–7 days 

 

 

 First-line therapy: 

 

 Azithromycin: 

 

 Day 1: 10 mg/kg/dose PO (max 500 mg/dose) 

 Days 2–5: 5 mg/kg/dose PO qDay (max 250 mg/dose) 

 

 

 Note: Resistance to azithromycin is significant among typical bacterial pathogens, especially Streptococcus pneumoniae . 

 

 

 Alternatives (without azithromycin): 

 

 Levofloxacin: 

 

 Ages 6 months–5 years: 8–10 mg/kg/dose PO BID 

 ≥5 years: 16–20 mg/kg/dose PO QD (max 750 mg/day) 

 

 

 Doxycycline (for children ≥8 years): 

 

 2 mg/kg/dose PO BID (max 100 mg/dose) 

 

 

 

 

 Notes: 

 

 Consider atypical pneumonia in adolescents with bilateral or diffuse pulmonary involvement and/or prolonged symptoms such as persistent cough and fever. 

 Levofloxacin and doxycycline provide excellent atypical pathogen coverage and do not require additional macrolides. 

 

 

 

 

 ACUTE BACTERIAL RHINOSINUSITIS (ABRS) 

 

 Criteria for Diagnosis: 

 

 Presumptive diagnosis of ABRS can be made if a patient with acute upper respiratory tract infection (URI) presents with ONE of the following:

 

 Persistent illness (e.g., nasal discharge, daytime cough, or both) lasting >10 days without improvement. 

 Worsening course after initial improvement (e.g., new onset nasal discharge, daytime cough, or fever). 

 Severe onset (e.g., fever ≥102.2°F and purulent nasal discharge) lasting at least 3 consecutive days. 

 

 

 

 

 Duration: 

 

 5–7 days 

 

 

 First-line therapy: 

 

 Mild-moderate disease (≥2 years, no daycare, no antibiotics in past 30 days): 

 

 Amoxicillin: 45–50 mg/kg PO BID (max 2000 mg/dose). 

 

 

 Severe disease or mild-moderate disease with any of the following: <2 years, daycare attendance, or recent antibiotic use: 

 

 Amoxicillin-clavulanate: 40–50 mg/kg/dose (amoxicillin component) PO BID (max 2000 mg/dose). 

 

 

 

 

 Penicillin Allergy: 

 

 Mild/Moderate—Rashes, including hives: 

 

 Cefpodoxime: 5 mg/kg/dose PO BID (max 200 mg/dose). 

 Cefuroxime: 250 mg PO BID (for children able to swallow tablets; not available in liquid form). 

 Cefixime: 4 mg/kg/dose PO BID (max 200 mg/dose) PLUS Clindamycin: 10 mg/kg/dose PO TID (max 600 mg/dose). 

 

 

 Severe—Anaphylaxis ± Cephalosporin Allergy: 

 

 Levofloxacin: 

 

 Ages 6 months–5 years: 10 mg/kg/dose PO BID. 

 ≥5 years: 20 mg/kg/dose PO QD (max 500 mg/day). 

 

 

 

 

 

 

 Notes: 

 

 If symptoms worsen or fail to improve after 48–72 hours, reassess for complications or switch to second-line therapy. 

 Consider consulting an infectious diseases physician for complex or recurrent cases. 

 

 

 

 

 CYSTITIS (UNCOMPLICATED UTI) 

 

 Duration: 

 

 3–5 days 

 

 

 First-line therapy: 

 

 Cephalexin: 50 mg/kg/day PO divided TID (max 1500 mg/day). 

 Cefixime: 8 mg/kg/dose PO qDay (max 400 mg/day). 

 

 

 Severe Penicillin/Cephalosporin Allergy (e.g., Anaphylaxis): 

 

 Trimethoprim-Sulfamethoxazole (TMP/SMX): 

 

 3–6 mg TMP/kg/dose PO BID (max 160 mg TMP/dose). 

 

 

 Nitrofurantoin (for cystitis only): 

 

 Macrocrystal (Macrodantin or Furadantin): 1.25–1.75 mg/kg/dose PO Q6H x 5–7 days (max 100 mg/dose). 

 Macrocrystal/monohydrate (Macrobid): 100 mg PO BID x 5–7 days ( adolescents only ). 

 

 

 

 

 Notes: 

 

 Nitrofurantoin should be used only for lower urinary tract infections and avoided in suspected pyelonephritis or febrile UTIs. 

 Avoid TMP/SMX in infants <2 months due to risk of kernicterus. 

 Consider urine culture and sensitivity for recurrent UTIs or treatment failures. 

 

 

 

 

 PYELONEPHRITIS (FEBRILE UTI) 

 

 Indications for Admission: 

 

 Age <2 months. 

 Ill appearance or poor oral intake. 

 Inability to tolerate oral antibiotics. 

 Vomiting, immune compromise, or urinary tract obstruction. 

 Positive culture for bacteria resistant to oral antibiotics. 

 

 

 Duration: 

 

 7–10 days. 

 Note: Shorter duration of 5 days may be sufficient for patients >2 months (Zaoutis et al., JAMA Pediatr. 2023 Aug 1;177(8):782-789). 

 

 

 First-line therapy: 

 

 Cephalexin: 25–33 mg/kg/dose PO TID (max 3000 mg/day). 

 Cefixime: 8 mg/kg/day PO qDay (max 400 mg/day). 

 

 

 Severe Penicillin/Cephalosporin Allergy (e.g., Anaphylaxis): 

 

 Trimethoprim-Sulfamethoxazole (TMP/SMX): 

 

 3–6 mg TMP/kg/dose PO BID (max 160 mg TMP/dose). 

 

 

 Ciprofloxacin: 

 

 10–20 mg/kg/dose PO BID (max 750 mg/dose). 

 

 

 

 

 Notes: 

 

 Cefdinir is not recommended for pediatric UTIs due to poor urine concentration in children. 

 Evaluate for potential complications, such as renal scarring or obstruction, especially in recurrent infections. 

 Obtain urine culture and sensitivity to guide therapy. 

 

 

 

 

 IMPETIGO 

 

 Treatment based on severity: 

 

 Mild (<5 lesions - topical therapy): 

 

 Mupirocin: Apply TID x 5 days. 

 

 

 Extensive (>5 lesions or lesions near the mouth - systemic therapy): 

 

 Cephalexin: 17 mg/kg/dose PO TID (max 500 mg/dose) x 7 days. 

 

 

 If MRSA is suspected or with severe penicillin/cephalosporin allergy: 

 

 Clindamycin: 7 mg/kg/dose PO TID (max 450 mg/dose) x 7 days. 

 Trimethoprim-Sulfamethoxazole (TMP/SMX): 

 

 4–6 mg TMP/kg/dose PO BID (max 160 mg TMP/dose) x 7 days. 

 

 

 

 

 

 

 Notes: 

 

 Systemic antibiotics are preferred if lesions are numerous, involve the mouth or mucosal areas, or in cases with signs of systemic infection. 

 Educate caregivers about proper hygiene to prevent the spread, as impetigo is highly contagious. 

 

 

 

 

 CELLULITIS / ABSCESS 

 

 First-line therapy: 

 

 Cephalexin: 17 mg/kg/dose PO TID (max 500 mg/dose) x 5 days. 

 Amoxicillin-clavulanate: 22.5 mg/kg/dose (amoxicillin component) PO BID (max 875 mg/dose). 

 

 

 If MRSA is suspected, abscess is present, or in cases of penicillin/cephalosporin allergy: 

 

 Clindamycin: 10 mg/kg/dose PO TID (max 450 mg/dose) x 5 days. 

 Trimethoprim-Sulfamethoxazole (TMP/SMX): 

 

 4–6 mg TMP/kg/dose PO BID (max 160 mg TMP/dose) x 5 days. 

 

 

 

 

 Notes: 

 

 For abscesses , incision and drainage (I&D) is the primary treatment; antibiotics may be considered based on the severity or associated cellulitis. 

 Reassess therapy if no improvement is noted after 48–72 hours. 

 Obtain cultures in cases of recurrent abscesses, systemic symptoms, or immunocompromised patients to guide therapy. 

 

 

 

 

 ANIMAL / HUMAN BITES 

 

 First-line therapy: 

 

 Amoxicillin-clavulanate (Augmentin): 22.5 mg/kg/dose (amoxicillin component) PO BID (max 875 mg amoxicillin/dose). 

 

 

 Duration: 

 

 Prophylaxis: 3 days. 

 Treatment: 5–7 days. 

 

 

 Penicillin Allergy: 

 

 Clindamycin: 10 mg/kg/dose PO TID (max 450 mg/dose) PLUS one of the following: 

 

 Trimethoprim-Sulfamethoxazole (TMP/SMX): 5 mg TMP/kg/dose PO BID (max 160 mg TMP/dose). 

 Doxycycline: 2.2 mg/kg/dose PO BID (max 100 mg/dose). 

 

 

 

 

 Additional Considerations: 

 

 Tetanus booster: Ensure vaccination status is updated. 

 Rabies prophylaxis: Assess need based on the animal and circumstances of the bite. 

 

 

 Notes: 

 

 Antibiotic prophylaxis is recommended for high-risk wounds, such as deep punctures, crush injuries, or bites on the hands, face, or genitals. 

 Monitor for signs of infection, including increasing redness, swelling, pain, or systemic symptoms. 

 

 

 

 

 DENTAL ABSCESS 

 

 First-line therapy: 

 

 Amoxicillin: 17 mg/kg/dose PO TID (max 500 mg/dose) x 10 days. 

 Amoxicillin-clavulanate (Augmentin): 25 mg/kg/dose (amoxicillin component) PO BID (max 875 mg amoxicillin/dose) x 10 days. 

 

 

 If buccal involvement or penicillin allergy: 

 

 Clindamycin: 10 mg/kg/dose PO TID (max 450 mg/dose) x 10 days. 

 

 

 Additional Considerations: 

 

 Incision and drainage (I&D) is often necessary for definitive management. 

 Dental consultation is recommended to address the underlying cause and prevent recurrence. 

 

 

 Notes: 

 

 For systemic symptoms (e.g., fever, swelling extending into facial spaces), hospitalization and IV antibiotics may be required. 

 Encourage dental hygiene and follow-up care to prevent complications or recurrence. 

 

 

 

 

 ACUTE LYMPHADENITIS 

 

 First-line therapy: 

 

 Cephalexin: 17–25 mg/kg/dose PO TID (max 1000 mg/dose) x 7–10 days. 

 Amoxicillin-clavulanate (Augmentin): 22.5 mg/kg/dose (amoxicillin component) PO BID (max 875 mg amoxicillin/dose) x 7–10 days. 

 

 

 If MRSA is suspected or with severe penicillin/cephalosporin allergy: 

 

 Clindamycin: 10 mg/kg/dose PO TID (max 450 mg/dose) x 7–10 days. 

 

 

 If Bartonella henselae (cat-scratch disease) is suspected: 

 

 Azithromycin: 10 mg/kg/dose PO qDay (max 500 mg/dose) x 5 days. 

 

 

 Additional Considerations: 

 

 Obtain cultures or imaging (e.g., ultrasound) if abscess formation is suspected. 

 Monitor closely for systemic symptoms such as fever, weight loss, or night sweats, which may warrant further investigation for atypical infections or malignancy. 

 

 

 Notes: 

 

 Typical bacterial causes include Staphylococcus aureus and Streptococcus pyogenes . 

 For children with recurrent or persistent lymphadenitis, consider consultation with an infectious diseases specialist. 

 

 

 

 

 ACUTE BACTERIAL CONJUNCTIVITIS 

 

 Infants (especially <2 months): 

 

 Erythromycin ointment (5 mg/g): Apply 1 cm to the affected eye QID for 5 days. 

 Polymyxin B ointment: Apply 1.25 cm to the affected eye QID for 5 days. 

 

 

 Children and adolescents: 

 

 Polymyxin B solution: 1 drop in the affected eye QID for 7 days. 

 

 

 Alternative topical therapies: 

 

 Tobramycin (0.3%) ophthalmic solution: Instill 1–2 drops into the affected eye every 4 hours. 

 Azithromycin (1%) ophthalmic solution: 

 

 Instill 1 drop into the affected eye BID (8–12 hours apart) on days 1–2. 

 Then, instill 1 drop daily into the affected eye on days 3–7. 

 Note: More expensive and harder to find than other alternatives. 

 

 

 

 

 If corneal involvement or patient wears contact lenses: 

 

 Consider alternatives with broader gram-negative coverage:

 

 Ciprofloxacin (0.3%) ophthalmic drops: Instill 1–2 drops in the affected eye 4 times daily. 

 Ofloxacin (0.3%) ophthalmic drops: Instill 1–2 drops in the affected eye 4 times daily. 

 

 

 

 

 Notes: 

 

 Avoid ophthalmic solutions containing neomycin due to a high incidence of allergic reactions. 

 For severe cases or if no improvement after 48 hours, consider bacterial resistance or alternative diagnoses such as viral conjunctivitis. 

 

 

 

 

 PERTUSSIS 

 Reportable - Must Notify Louisiana Department of Health; Must stay home until completed antibiotics 

 

 Indications for Treatment: 

 

 Confirmed or suspected pertussis cases. 

 Prophylaxis for close contacts of pertussis cases, especially high-risk individuals (e.g., infants, pregnant women, or those with immunocompromised household members). 

 

 

 Duration: 

 

 5–7 days depending on the selected antibiotic. 

 

 

 First-line therapy (macrolides): 

 

 Azithromycin: 

 

 Infants <6 months: 10 mg/kg/dose PO qDay x 5 days 

 ≥6 months:

 

 Day 1: 10 mg/kg/dose PO (max 500 mg/dose) 

 Days 2–5: 5 mg/kg/dose PO qDay (max 250 mg/dose) 

 

 

 

 

 Clarithromycin: 

 

 7.5 mg/kg/dose PO BID (max 500 mg/dose) x 7 days 

 

 

 

 

 Alternative therapy (if macrolides are contraindicated): 

 

 Trimethoprim-Sulfamethoxazole (TMP/SMX): 

 

 4–6 mg TMP/kg/dose PO BID (max 160 mg TMP/dose) x 14 days 

 

 

 

 

 Notes: 

 

 Azithromycin is preferred for infants <1 month due to safety concerns with erythromycin (risk of hypertrophic pyloric stenosis). 

 TMP/SMX should be avoided in infants <2 months due to the risk of kernicterus. 

 Early treatment is critical to limit transmission, but treatment after the paroxysmal stage may not alter the course of symptoms.