Loading

Does the patient have a penicillin allergy? (See below for details on penicillin allergy severity)

• No penicillin allergy
• Non-severe immediate or delayed penicillin hypersensitivity
• Severe immediate or delayed penicillin hypersensitivity

History of penicillin allergy or adverse reaction

No penicillin allergy

• This includes non-severe reactions such as nausea and limited diarrhoea
• Such reactions are frequently not replicable or generalizable to the whole class. It is safe to prescribe penicillin class antibiotics (with the patient’s knowledge), and if required, use strategies for symptom control such as metoclopramide

Non-severe immediate or delayed penicillin hypersensitivity

• This includes non-severe reactions such as isolated rash
• There is only a 2-3% chance of cephalosporin allergy in a patient with a previous IgE mediated allergy to penicillin, and probably even less for other types of allergies. In most cases it is safe to administer a cephalosporin to a patient who has had a non-life threatening reaction to penicillin

Severe immediate or delayed penicillin hypersensitivity

• This includes anaphylaxis (see below) BUT DOES NOT INCLUDE other life-threatening reactions such as Stevens-Johnson Syndrome (SJS), Toxic epidermal necrolysis (TEN), Drug reaction with eosinophilia and systemic symptoms (DRESS) or interstitial nephritis. If your patient has a history of these, contact infectious diseases for advice

Penicillin anaphylaxis is highly likely if any ONE of the following is fulfilled:

OR

OR

Does the patient have any risk factors for Pseudamonus aeruginosa infection? (See below)

• Yes
• No

Does the patient have any risk factors for Pseudamonus aeruginosa infection? (See below)

• Yes
• No

Does the patient have any risk factors for Pseudamonus aeruginosa infection? (See below)

• Yes
• No

If the patient has no penicillin allergy and risk factors for Pseudomonas aeruginosa infection give:

THEN, following a minimum of FIVE days of antibiotic therapy, switch to oral. If Pseudomonas aeruginosa is identified by culture and the isolate is susceptible to ciprofloxacin use:

Code for Piperacillin + tazobactam IV is: 7mas

This code is valid for SEVEN days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past one week. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

Code for Ciprofloxacin PO is: 10mas

This code is valid for TEN days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past ten days. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• If a pathogen is not identified, switch to an appropriate narrower-spectrum empirical regimen (see treatment options for patients without Pseudomonas infection)
• Ciprofloxacin is not licensed for use in children on the basis of animal studies that showed an adverse effect on cartilage development with quinolone use; however, there are few data from human trials to support this finding. Ciprofloxacin can be used in children when it is the drug of choice
• Management of acute mastoiditis in children requires initial intravenous antibiotic therapy, and consultation with an otolaryngologist for consideration of aspiration and drainage of the middle ear, or mastoidectomy. Collect samples from the middle ear and, if possible, the mastoid cavity for culture and susceptibility testing
• See the Australian Therapeutic Guidelines Antibiotic for instructions on when to make the IV to oral switch
• Children with intracranial complications may require a longer duration of therapy—contact infectious diseases for advice
• Acute mastoiditis is most common in children younger than 2 years of age, but complications of acute mastoiditis are more frequent in children 2 years or older. Complications of mastoiditis include subperiosteal, subcutaneous, intratemporal or intracranial collections, and facial nerve palsy
• For the management of children with intracranial complications, such as meningitis, seek expert advice

References:

See section on acute mastoiditis in children - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

If the patient has no penicillin allergy give:

THEN, following a minimum of FIVE days of antibiotic therapy, switch to oral. If no pathogen is identified on microbiology use:

Code for ceftriaxone or cefotaxime is: 7mas

This code is valid for SEVEN days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past one week. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• Management of acute mastoiditis in children requires initial intravenous antibiotic therapy, and consultation with an otolaryngologist for consideration of aspiration and drainage of the middle ear, or mastoidectomy. Collect samples from the middle ear and, if possible, the mastoid cavity for culture and susceptibility testing
• See the Australian Therapeutic Guidelines Antibiotic for instructions on when to make the IV to oral switch
• Children with intracranial complications may require a longer duration of therapy—contact infectious diseases for advice
• Acute mastoiditis is most common in children younger than 2 years of age, but complications of acute mastoiditis are more frequent in children 2 years or older. Complications of mastoiditis include subperiosteal, subcutaneous, intratemporal or intracranial collections, and facial nerve palsy
• For the management of children with intracranial complications, such as meningitis, seek expert advice

References:

See section on acute mastoiditis in children - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

If the patient has non-severe penicillin allergy and risk factors for Pseudomonas aeruginosa infection give:

THEN, following a minimum of FIVE days of antibiotic therapy, switch to oral. If Pseudomonas aeruginosa is identified by culture and the isolate is susceptible to ciprofloxacin use:

Code for Ceftazidime IV is: 7mas

This code is valid for SEVEN days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past one week. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

Code for Ciprofloxacin PO is: 10mas

This code is valid for TEN days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past ten days. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• If a pathogen is not identified, switch to an appropriate narrower-spectrum empirical regimen (see treatment options for patients without Pseudomonas infection)
• Ciprofloxacin is not licensed for use in children on the basis of animal studies that showed an adverse effect on cartilage development with quinolone use; however, there are few data from human trials to support this finding. Ciprofloxacin can be used in children when it is the drug of choice
• Management of acute mastoiditis in children requires initial intravenous antibiotic therapy, and consultation with an otolaryngologist for consideration of aspiration and drainage of the middle ear, or mastoidectomy. Collect samples from the middle ear and, if possible, the mastoid cavity for culture and susceptibility testing
• See the Australian Therapeutic Guidelines Antibiotic for instructions on when to make the IV to oral switch
• Children with intracranial complications may require a longer duration of therapy—contact infectious diseases for advice
• Acute mastoiditis is most common in children younger than 2 years of age, but complications of acute mastoiditis are more frequent in children 2 years or older. Complications of mastoiditis include subperiosteal, subcutaneous, intratemporal or intracranial collections, and facial nerve palsy
• For the management of children with intracranial complications, such as meningitis, seek expert advice

References:

See section on acute mastoiditis in children - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

If the patient has non-severe penicillin allergy give:

THEN, following a minimum of FIVE days of antibiotic therapy, switch to oral. If no pathogen is identified on microbiology use:

Code for ceftriaxone or cefotaxime is: 7mas

This code is valid for SEVEN days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past one week. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

Code for cefuroxime is: 10mas

This code is valid for TEN days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past ten days. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• Management of acute mastoiditis in children requires initial intravenous antibiotic therapy, and consultation with an otolaryngologist for consideration of aspiration and drainage of the middle ear, or mastoidectomy. Collect samples from the middle ear and, if possible, the mastoid cavity for culture and susceptibility testing
• See the Australian Therapeutic Guidelines Antibiotic for instructions on when to make the IV to oral switch
• Children with intracranial complications may require a longer duration of therapy—contact infectious diseases for advice
• Acute mastoiditis is most common in children younger than 2 years of age, but complications of acute mastoiditis are more frequent in children 2 years or older. Complications of mastoiditis include subperiosteal, subcutaneous, intratemporal or intracranial collections, and facial nerve palsy
• For the management of children with intracranial complications, such as meningitis, seek expert advice

References:

See section on acute mastoiditis in children - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

If the patient has severe penicillin allergy and risk factors for Pseudomonas aeruginosa infection consider:

THEN, following a minimum of FIVE days of antibiotic therapy, switch to oral. If Pseudomonas aeruginosa is identified by culture and the isolate is susceptible to ciprofloxacin use:

Code for Meropenem is: 7mas

This code is valid for SEVEN days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past one week. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

Code for Ciprofloxacin PO is: 10mas

This code is valid for TEN days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past ten days. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• In patients with penicillin hypersensitivity, the rate of immune-mediated cross-reactivity with carbapenems is approximately 1%; therefore, meropenem can be considered in supervised settings. However, in patients with a history of a severe cutaneous adverse reaction (eg drug rash with eosinophilia and systemic symptoms [DRESS], Stevens–Johnson syndrome / toxic epidermal necrolysis [SJS/TEN], acute generalised exanthematous pustulosis [AGEP]), consider meropenem only in a critical situation when there are limited treatment options
• If a pathogen is not identified, switch to an appropriate narrower-spectrum empirical regimen (see treatment options for patients without Pseudomonas infection)
• Ciprofloxacin is not licensed for use in children on the basis of animal studies that showed an adverse effect on cartilage development with quinolone use; however, there are few data from human trials to support this finding. Ciprofloxacin can be used in children when it is the drug of choice
• Management of acute mastoiditis in children requires initial intravenous antibiotic therapy, and consultation with an otolaryngologist for consideration of aspiration and drainage of the middle ear, or mastoidectomy. Collect samples from the middle ear and, if possible, the mastoid cavity for culture and susceptibility testing
• See the Australian Therapeutic Guidelines Antibiotic for instructions on when to make the IV to oral switch
• Children with intracranial complications may require a longer duration of therapy—contact infectious diseases for advice
• Acute mastoiditis is most common in children younger than 2 years of age, but complications of acute mastoiditis are more frequent in children 2 years or older. Complications of mastoiditis include subperiosteal, subcutaneous, intratemporal or intracranial collections, and facial nerve palsy
• For the management of children with intracranial complications, such as meningitis, seek expert advice

References:

See section on acute mastoiditis in children - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

If the patient has severe penicillin allergy give:

THEN, following a minimum of FIVE days of antibiotic therapy, switch to oral. If no pathogen is identified on microbiology use:

Code for vancomycin is: 7mas

This code is valid for SEVEN days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past one week. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

Code for Azithromycin PO is: 10mas

This code is valid for TEN days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past ten days. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• Management of acute mastoiditis in children requires initial intravenous antibiotic therapy, and consultation with an otolaryngologist for consideration of aspiration and drainage of the middle ear, or mastoidectomy. Collect samples from the middle ear and, if possible, the mastoid cavity for culture and susceptibility testing
• See the Australian Therapeutic Guidelines Antibiotic for instructions on when to make the IV to oral switch
• Children with intracranial complications may require a longer duration of therapy—contact infectious diseases for advice
• Acute mastoiditis is most common in children younger than 2 years of age, but complications of acute mastoiditis are more frequent in children 2 years or older. Complications of mastoiditis include subperiosteal, subcutaneous, intratemporal or intracranial collections, and facial nerve palsy
• For the management of children with intracranial complications, such as meningitis, seek expert advice

Vancomycin Dosing in Paediatrics

1. Vancomycin should be administered at a maximum rate of 10 mg/min to avoid Red Person Syndrome
2. "Trough" levels are taken within 60 minutes of the next dose. If a loading dose is given then it is considered the first dose
3. In patients with CrClr < 20 mL/min, the clinical context (e.g haemodialysis) determines whether the next dose is given before the trough concentration is available or withheld until the result is known

• Please contact infectious diseases within 48 hours of initiating therapy with vancomycin
• Watch baseline creatinine closely while treating a patient with vancomycin. An increase from baseline creatinine will almost always result in an increase in vancomycin concentration as vancomycin is 40-100% renally cleared. A sudden dramatic increase in creatinine should always prompt an immediate vancomycin level prior to the next dose, witholding the next dose until the level is available
• If a dose is missed or delayed within 48 hours of taking a level please contact pharmacy for interpretation of trough levels as vancomycin will not have reached steady state

References:

See section on acute mastoiditis in children - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

Does the patient have a penicillin allergy? (See below for details on penicillin allergy severity)

• No penicillin allergy
• Non-severe immediate or delayed penicillin hypersensitivity
• Severe immediate or delayed penicillin hypersensitivity

History of penicillin allergy or adverse reaction

No penicillin allergy

• This includes non-severe reactions such as nausea and limited diarrhoea
• Such reactions are frequently not replicable or generalizable to the whole class. It is safe to prescribe penicillin class antibiotics (with the patient’s knowledge), and if required, use strategies for symptom control such as metoclopramide

Non-severe immediate or delayed penicillin hypersensitivity

• This includes non-severe reactions such as isolated rash
• There is only a 2-3% chance of cephalosporin allergy in a patient with a previous IgE mediated allergy to penicillin, and probably even less for other types of allergies. In most cases it is safe to administer a cephalosporin to a patient who has had a non-life threatening reaction to penicillin

Severe immediate or delayed penicillin hypersensitivity

• This includes anaphylaxis (see below) BUT DOES NOT INCLUDE other life-threatening reactions such as Stevens-Johnson Syndrome (SJS), Toxic epidermal necrolysis (TEN), Drug reaction with eosinophilia and systemic symptoms (DRESS) or interstitial nephritis. If your patient has a history of these, contact infectious diseases for advice

Penicillin anaphylaxis is highly likely if any ONE of the following is fulfilled:

OR

OR

Epiglottitis treatment:

Code for ceftriaxone or cefotaxime is: 5epg

This code is valid for FIVE days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past 5 days. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• The addition of corticosteroids to reduce airway inflammation is controversial but widespread
• Most experts recommend a total duration of 7 to 10 days (IV + PO)
• Switch to appropriate oral therapy once the patient improves, guided by the results of culture and susceptibility testing. See eTG for recommended step down options
• Treatment of acute epiglottitis requires airway maintenance. All patients require intensive monitoring. Seek expert advice from ENT or infectious diseases

References:

See section on epiglottitis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

For epiglottitis in a patient with life threatening penicillin hypersensitivity:

Code for IV moxifloxacin is: 5epg

This code is valid for FIVE days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past 5 days. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• The addition of corticosteroids to reduce airway inflammation is controversial but widespread
• Most experts recommend a total duration of 7 to 10 days (IV + PO)
• Switch to appropriate oral therapy once the patient improves, guided by the results of culture and susceptibility testing. See eTG for recommended step down options
• Treatment of acute epiglottitis requires airway maintenance. All patients require intensive monitoring. Seek expert advice from ENT or infectious diseases

References:

See section on epiglottitis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

Does the patient have otitis media or externa? (see below)

• Otitis media
• Acute diffuse otitis externa

• Acute diffuse otitis externa (swimmers ear) typically presents with ear pain, pruritus and hearing loss. There may also be tenderness on manipulation of the tragus or auricle, and discharge may be present. In more severe cases, there may be regional lymphadenitis, or cellulitis of the pinna and adjacent skin

How severe is the infection? (see below)

• Mild to moderate
• Severe

• Severe cases of acute diffuse bacterial acute diffuse otitis externa present with intense pain and complete occlusion of the external ear canal. Fever and extension of infection beyond the ear canal may also occur. In any case with associated fever treat as severe acute diffuse otitis externa

Does the patient have suspected fungal infection?

• Yes
• No

• Debridement and dry aural toilet are the mainstays of treatment of fungal infection (otomycosis)

If there is unlikely to be fungal infection give:

• If possible, avoid products containing an aminoglycoside (eg framycetin, neomycin) in patients with a perforated tympanic membrane or a tympanostomy tube in situ because of the risk of inner ear damage
• If ear drops cannot be instilled because the canal is occluded, inserting a wick into the occluded ear canal can facilitate ear drop administration
• Advise the patient to keep the ear dry during and for 2 weeks after treatment. This can be achieved by using earplugs (although canal tenderness may limit their use) or a shower or bathing cap during showering and swimming
• If aminoglycoside-containing products cannot be avoided, they can be used with caution because treatment is of short duration
• Debridement and dry aural toilet are the mainstays of treatment of fungal infection (otomycosis)
• Instil combination corticosteroid and antimicrobial ear drops after performing dry aural toilet
• After ear drops are instilled, apply gentle pressure to the tragus (by pressing on it repeatedly without causing pain) for 30 seconds
• It is not necessary to routinely perform culture to guide antimicrobial therapy in non-severe cases of acute diffuse otitis externa
• If symptoms persist despite appropriate acute diffuse otitis externa treatment, consider noninfectious causes such as contact dermatitis, atopic dermatitis or seborrhoeic dermatitis

References:

See section on Acute diffuse otitis externa - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

If there is likely to be fungal infection give:

• If possible, avoid products containing an aminoglycoside (eg framycetin, neomycin) in patients with a perforated tympanic membrane or a tympanostomy tube in situ because of the risk of inner ear damage
• Advise the patient to keep the ear dry during and for 2 weeks after treatment. This can be achieved by using earplugs (although canal tenderness may limit their use) or a shower or bathing cap during showering and swimming
• If ear drops cannot be instilled because the canal is occluded, inserting a wick into the occluded ear canal can facilitate ear drop administration
• If aminoglycoside-containing products cannot be avoided, they can be used with caution because treatment is of short duration
• Debridement and dry aural toilet are the mainstays of treatment of fungal infection (otomycosis)
• Instil combination corticosteroid and antimicrobial ear drops after performing dry aural toilet
• After ear drops are instilled, apply gentle pressure to the tragus (by pressing on it repeatedly without causing pain) for 30 seconds
• It is not necessary to routinely perform culture to guide antimicrobial therapy in non-severe cases of acute diffuse otitis externa
• If symptoms persist despite appropriate acute diffuse otitis externa treatment, consider noninfectious causes such as contact dermatitis, atopic dermatitis or seborrhoeic dermatitis

References:

See section on acute diffuse otitis externa - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

Does the patient have a penicillin allergy? See below for details on penicillin allergy severity

• No penicillin allergy
• Non-severe immediate or delayed penicillin hypersensitivity
• Severe immediate or delayed penicillin hypersensitivity

History of penicillin allergy or adverse reaction

No penicillin allergy

• This includes non-severe reactions such as nausea and limited diarrhoea
• Such reactions are frequently not replicable or generalizable to the whole class. It is safe to prescribe penicillin class antibiotics (with the patient’s knowledge), and if required, use strategies for symptom control such as metoclopramide

Non-severe immediate or delayed penicillin hypersensitivity

• This includes non-severe reactions such as isolated rash
• There is only a 2-3% chance of cephalosporin allergy in a patient with a previous IgE mediated allergy to penicillin, and probably even less for other types of allergies. In most cases it is safe to administer a cephalosporin to a patient who has had a non-life threatening reaction to penicillin

Severe immediate or delayed penicillin hypersensitivity

• This includes anaphylaxis (see below) BUT DOES NOT INCLUDE other life-threatening reactions such as Stevens-Johnson Syndrome (SJS), Toxic epidermal necrolysis (TEN), Drug reaction with eosinophilia and systemic symptoms (DRESS) or interstitial nephritis. If your patient has a history of these, contact infectious diseases for advice

Penicillin anaphylaxis is highly likely if any ONE of the following is fulfilled:

OR

OR

For severe acute diffuse otitis externa with no penicillin allergy give both topical and systemic therapy:

For the topical agent use:

For the systemic agents use:

Code for ciprofloxacin is: 10ote

This code is valid for TEN days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if IV treatment is to continue past ten days. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• Cefalexin is often preferred to flucloxacillin in children because the liquid formulation is better tolerated
• Ciprofloxacin is not licensed for use in children on the basis of animal studies that showed an adverse effect on cartilage development with quinolone use; however, there are few data from human trials to support this finding. Ciprofloxacin can be used in children when it is the drug of choice.
• An oral liquid formulation of ciprofloxacin is not commercially available; for formulation options for children or people with swallowing difficulties, see the Don’t Rush to Crush Handbook, published by the Society of Hospital Pharmacists of Australia
• If possible, avoid products containing an aminoglycoside (eg framycetin, neomycin) in patients with a perforated tympanic membrane or a tympanostomy tube in situ because of the risk of inner ear damage
• Advise the patient to keep the ear dry during and for 2 weeks after treatment. This can be achieved by using earplugs (although canal tenderness may limit their use) or a shower or bathing cap during showering and swimming
• If ear drops cannot be instilled because the canal is occluded, inserting a wick into the occluded ear canal can facilitate ear drop administration
• If aminoglycoside-containing products cannot be avoided, they can be used with caution because treatment is of short duration
• Debridement and dry aural toilet are the mainstays of treatment of fungal infection (otomycosis)
• Instil combination corticosteroid and antimicrobial ear drops after performing dry aural toilet
• After ear drops are instilled, apply gentle pressure to the tragus (by pressing on it repeatedly without causing pain) for 30 seconds
• It is not necessary to routinely perform culture to guide antimicrobial therapy in non-severe cases of acute diffuse otitis externa
• If symptoms persist despite appropriate acute diffuse otitis externa treatment, consider noninfectious causes such as contact dermatitis, atopic dermatitis or seborrhoeic dermatitis

References:

See section on acute diffuse otitis externa - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

For severe acute diffuse otitis externa with delayed non-severe penicillin hypersensitivity give both topical and systemic therapy:

For the topical agent use:

For the systemic agents use:

Code for ciprofloxacin is: 10ote

This code is valid for TEN days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if IV treatment is to continue past ten days. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• Ciprofloxacin is not licensed for use in children on the basis of animal studies that showed an adverse effect on cartilage development with quinolone use; however, there are few data from human trials to support this finding. Ciprofloxacin can be used in children when it is the drug of choice.
• An oral liquid formulation of ciprofloxacin is not commercially available; for formulation options for children or people with swallowing difficulties, see the Don’t Rush to Crush Handbook, published by the Society of Hospital Pharmacists of Australia
• If possible, avoid products containing an aminoglycoside (eg framycetin, neomycin) in patients with a perforated tympanic membrane or a tympanostomy tube in situ because of the risk of inner ear damage
• Advise the patient to keep the ear dry during and for 2 weeks after treatment. This can be achieved by using earplugs (although canal tenderness may limit their use) or a shower or bathing cap during showering and swimming
• If ear drops cannot be instilled because the canal is occluded, inserting a wick into the occluded ear canal can facilitate ear drop administration
• If aminoglycoside-containing products cannot be avoided, they can be used with caution because treatment is of short duration
• Debridement and dry aural toilet are the mainstays of treatment of fungal infection (otomycosis)
• Instil combination corticosteroid and antimicrobial ear drops after performing dry aural toilet
• After ear drops are instilled, apply gentle pressure to the tragus (by pressing on it repeatedly without causing pain) for 30 seconds
• It is not necessary to routinely perform culture to guide antimicrobial therapy in non-severe cases of acute diffuse otitis externa
• If symptoms persist despite appropriate acute diffuse otitis externa treatment, consider noninfectious causes such as contact dermatitis, atopic dermatitis or seborrhoeic dermatitis

References:

See section on acute diffuse otitis externa - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

For severe acute diffuse otitis externa with no penicillin allergy give both topical and systemic therapy:

For the topical agent use:

For the systemic agents use:

Code for ciprofloxacin and clindamycin is: 10ote

This code is valid for TEN days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if IV treatment is to continue past ten days. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• Ciprofloxacin is not licensed for use in children on the basis of animal studies that showed an adverse effect on cartilage development with quinolone use; however, there are few data from human trials to support this finding. Ciprofloxacin can be used in children when it is the drug of choice.
• An oral liquid formulation of ciprofloxacin is not commercially available; for formulation options for children or people with swallowing difficulties, see the Don’t Rush to Crush Handbook, published by the Society of Hospital Pharmacists of Australia
• If possible, avoid products containing an aminoglycoside (eg framycetin, neomycin) in patients with a perforated tympanic membrane or a tympanostomy tube in situ because of the risk of inner ear damage
• Advise the patient to keep the ear dry during and for 2 weeks after treatment. This can be achieved by using earplugs (although canal tenderness may limit their use) or a shower or bathing cap during showering and swimming
• If ear drops cannot be instilled because the canal is occluded, inserting a wick into the occluded ear canal can facilitate ear drop administration
• If aminoglycoside-containing products cannot be avoided, they can be used with caution because treatment is of short duration
• Debridement and dry aural toilet are the mainstays of treatment of fungal infection (otomycosis)
• Instil combination corticosteroid and antimicrobial ear drops after performing dry aural toilet
• After ear drops are instilled, apply gentle pressure to the tragus (by pressing on it repeatedly without causing pain) for 30 seconds
• It is not necessary to routinely perform culture to guide antimicrobial therapy in non-severe cases of acute diffuse otitis externa
• If symptoms persist despite appropriate acute diffuse otitis externa treatment, consider noninfectious causes such as contact dermatitis, atopic dermatitis or seborrhoeic dermatitis

References:

See section on otitis externa - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

Does the patient have a penicillin allergy? See below for details on penicillin allergy severity

• No penicillin allergy
• Non-severe immediate or delayed penicillin hypersensitivity
• Severe immediate or delayed penicillin hypersensitivity

History of penicillin allergy or adverse reaction

No penicillin allergy

• This includes non-severe reactions such as nausea and limited diarrhoea
• Such reactions are frequently not replicable or generalizable to the whole class. It is safe to prescribe penicillin class antibiotics (with the patient’s knowledge), and if required, use strategies for symptom control such as metoclopramide

Non-severe immediate or delayed penicillin hypersensitivity

• This includes non-severe reactions such as isolated rash
• There is only a 2-3% chance of cephalosporin allergy in a patient with a previous IgE mediated allergy to penicillin, and probably even less for other types of allergies. In most cases it is safe to administer a cephalosporin to a patient who has had a non-life threatening reaction to penicillin

Severe immediate or delayed penicillin hypersensitivity

• This includes anaphylaxis (see below) BUT DOES NOT INCLUDE other life-threatening reactions such as Stevens-Johnson Syndrome (SJS), Toxic epidermal necrolysis (TEN), Drug reaction with eosinophilia and systemic symptoms (DRESS) or interstitial nephritis. If your patient has a history of these, contact infectious diseases for advice

Penicillin anaphylaxis is highly likely if any ONE of the following is fulfilled:

OR

OR

Has the patient already been treated for 48-72 hours and not responded to treatment?

• No, (this is initial therapy)
• Yes, (not responding to conventional treatment)

• Children who have not responded adequately to amoxicillin therapy by 48 to 72 hours may have infection caused by a beta-lactamase–producing strain of Haemophilus influenzae or Moraxella catarrhalis. Adding clavulanate to amoxicillin provides increased activity against these pathogens

In most cases antibiotics are not necessary (see below) if antibiotic treatment is required give:

• For most children with acute otitis media, antibiotic therapy can be safely withheld. However, antibiotic therapy is required in the following groups:
  • infants younger than 6 months
  • children younger than 2 years with bilateral infection
  • children who are systemically unwell (eg lethargic, pale, very irritable); fever alone is not an indication for antibiotic therapy
  • children with otorrhoea
  • Aboriginal and Torres Strait Islander children—for treatment recommendations, see the Recommendations for clinical care guidelines on the management of otitis media in Aboriginal and Torres Strait Islander populations
  • children at high risk of complications (eg immunocompromised children)
• Antibiotic treatment is not required for children with otitis media with effusion
• Do not use lower amoxicillin doses because they will not achieve adequate plasma and tissue concentrations to treat resistant Streptococcus pneumoniae strains
• For every 100 children treated with antibiotics, only five children will be better at 2 to 3 days as a consequence of taking antibiotics
• Many patients have an expectation of treatment with antibiotics. For children who do not require initial antibiotic therapy, effective communication with the patient or carer about the limited role of antibiotics in acute otitis media is essential. The discussion should address misconceptions about the effectiveness of antibiotic therapy and the expectation of an antibiotic prescription.
• Controlled trials showed decongestants, antihistamines and oral corticosteroids are not beneficial for acute otitis media

References:

See section on otitis media - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

If no response to previous antibiotic treatment give:

• For most children with acute otitis media, antibiotic therapy can be safely withheld. However, antibiotic therapy is required in the following groups:
  • infants younger than 6 months
  • children younger than 2 years with bilateral infection
  • children who are systemically unwell (eg lethargic, pale, very irritable); fever alone is not an indication for antibiotic therapy
  • children with otorrhoea
  • Aboriginal and Torres Strait Islander children—for treatment recommendations, see the Recommendations for clinical care guidelines on the management of otitis media in Aboriginal and Torres Strait Islander populations
  • children at high risk of complications (eg immunocompromised children)
• Antibiotic treatment is not required for children with otitis media with effusion
• Do not use lower amoxicillin doses because they will not achieve adequate plasma and tissue concentrations to treat resistant Streptococcus pneumoniae strains
• For every 100 children treated with antibiotics, only five children will be better at 2 to 3 days as a consequence of taking antibiotics
• Many patients have an expectation of treatment with antibiotics. For children who do not require initial antibiotic therapy, effective communication with the patient or carer about the limited role of antibiotics in acute otitis media is essential. The discussion should address misconceptions about the effectiveness of antibiotic therapy and the expectation of an antibiotic prescription.
• Controlled trials showed decongestants, antihistamines and oral corticosteroids are not beneficial for acute otitis media

References:

See section on otitis media - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

In most cases antibiotics are not necessary (see below) if antibiotic treatment is required give:

• For most children with acute otitis media, antibiotic therapy can be safely withheld. However, antibiotic therapy is required in the following groups:
  • infants younger than 6 months
  • children younger than 2 years with bilateral infection
  • children who are systemically unwell (eg lethargic, pale, very irritable); fever alone is not an indication for antibiotic therapy
  • children with otorrhoea
  • Aboriginal and Torres Strait Islander children—for treatment recommendations, see the Recommendations for clinical care guidelines on the management of otitis media in Aboriginal and Torres Strait Islander populations
  • children at high risk of complications (eg immunocompromised children)
• Antibiotic treatment is not required for children with otitis media with effusion
• Do not use lower amoxicillin doses because they will not achieve adequate plasma and tissue concentrations to treat resistant Streptococcus pneumoniae strains
• For every 100 children treated with antibiotics, only five children will be better at 2 to 3 days as a consequence of taking antibiotics
• Many patients have an expectation of treatment with antibiotics. For children who do not require initial antibiotic therapy, effective communication with the patient or carer about the limited role of antibiotics in acute otitis media is essential. The discussion should address misconceptions about the effectiveness of antibiotic therapy and the expectation of an antibiotic prescription.
• Controlled trials showed decongestants, antihistamines and oral corticosteroids are not beneficial for acute otitis media

References:

See section on otitis media - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

In most cases antibiotics are not necessary (see below) if antibiotic treatment is required give:

• For most children with acute otitis media, antibiotic therapy can be safely withheld. However, antibiotic therapy is required in the following groups:
  • infants younger than 6 months
  • children younger than 2 years with bilateral infection
  • children who are systemically unwell (eg lethargic, pale, very irritable); fever alone is not an indication for antibiotic therapy
  • children with otorrhoea
  • Aboriginal and Torres Strait Islander children—for treatment recommendations, see the Recommendations for clinical care guidelines on the management of otitis media in Aboriginal and Torres Strait Islander populations
  • children at high risk of complications (eg immunocompromised children)
• Antibiotic treatment is not required for children with otitis media with effusion
• Do not use lower amoxicillin doses because they will not achieve adequate plasma and tissue concentrations to treat resistant Streptococcus pneumoniae strains
• For every 100 children treated with antibiotics, only five children will be better at 2 to 3 days as a consequence of taking antibiotics
• Many patients have an expectation of treatment with antibiotics. For children who do not require initial antibiotic therapy, effective communication with the patient or carer about the limited role of antibiotics in acute otitis media is essential. The discussion should address misconceptions about the effectiveness of antibiotic therapy and the expectation of an antibiotic prescription.
• Controlled trials showed decongestants, antihistamines and oral corticosteroids are not beneficial for acute otitis media

References:

See section on otitis media - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

Does the patient have a penicillin allergy? (See below for details on penicillin allergy severity)

• No penicillin allergy
• Non-severe immediate or delayed penicillin hypersensitivity
• Severe immediate or delayed penicillin hypersensitivity

History of penicillin allergy or adverse reaction

No penicillin allergy

• This includes non-severe reactions such as nausea and limited diarrhoea
• Such reactions are frequently not replicable or generalizable to the whole class. It is safe to prescribe penicillin class antibiotics (with the patient’s knowledge), and if required, use strategies for symptom control such as metoclopramide

Non-severe immediate or delayed penicillin hypersensitivity

• This includes non-severe reactions such as isolated rash
• There is only a 2-3% chance of cephalosporin allergy in a patient with a previous IgE mediated allergy to penicillin, and probably even less for other types of allergies. In most cases it is safe to administer a cephalosporin to a patient who has had a non-life threatening reaction to penicillin

Severe immediate or delayed penicillin hypersensitivity

• This includes anaphylaxis (see below) BUT DOES NOT INCLUDE other life-threatening reactions such as Stevens-Johnson Syndrome (SJS), Toxic epidermal necrolysis (TEN), Drug reaction with eosinophilia and systemic symptoms (DRESS) or interstitial nephritis. If your patient has a history of these, contact infectious diseases for advice

Penicillin anaphylaxis is highly likely if any ONE of the following is fulfilled:

OR

OR

If the patient has no penicillin allergy give:

• A 12-hourly dosing regimen for phenoxymethylpenicillin is preferred over more frequent dosing regimens because of improved adherence
• Monitor patients for signs of airway obstruction. If present, urgent airway management is required
• Drainage or aspiration of the abscess is the mainstay of treatment for peritonsillar abscess

References:

See section on peritonsillar abscess and cellulitis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

If the patient has non-severe penicillin hypersensitivity give:

Code for clindamycin IV is: 3qui

This code is valid for THREE days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past 72 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

Code for clindamycin orally is: 10qui

This code is valid for TEN days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past ten days. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• Monitor patients for signs of airway obstruction. If present, urgent airway management is required
• Drainage or aspiration of the abscess is the mainstay of treatment for peritonsillar abscess
• Oral liquid formulations of clindamycin have an unpleasant taste and are often poorly tolerated by children

References:

See section on peritonsillar abscess and cellulitis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

If the patient has non-severe penicillin hypersensitivity give:

Code for clindamycin IV is: 3qui

This code is valid for THREE days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past 72 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

Code for azithromycin orally is: 5qui

This code is valid for FIVE days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past five days. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• Monitor patients for signs of airway obstruction. If present, urgent airway management is required
• Drainage or aspiration of the abscess is the mainstay of treatment for peritonsillar abscess
• Oral liquid formulations of clindamycin have an unpleasant taste and are often poorly tolerated by children

References:

See section on peritonsillar abscess and cellulitis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.