Pediatric Infectious Disease - Clinical Guidelines

Infectious diseases are among the most common reasons children present to community clinics and emergency departments in Israel. As a doctor or parent, you're bound to encounter them a lot!

This blog is designed as a practical, simple reference for the management of common pediatric infections. It reflects local epidemiology, antibiotic resistance patterns, available medications, and current Israeli guidelines.

This content is based on a 2025 Clalit Infectious Disease Guide, and edited by our esteemed ADII colleague; Dr Michael Dinerman; General Pediatric and Pediatric Emergency Medicine Specialist.

Download the full guide here:

Clalit Infectious Disease Guide

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Skin Infections (including Impetigo)

① Localized infections: 

→ Topical anti-bacterial creams:

✔ Mupirocin (Bactroban) Ointment

✔ Fusidic acid (Fucidin) Cream

✔ Gentamicin (Gentatrim) Ointment

→ Two or three times daily until resolved.

→  If no significant improvement switch to alternative ointment or add oral antibiotics.

→ In recurrent skin infections (especially impetigo), recommend chlorhexidine body wash. 

② Systemic/complicated infections:

→ Oral antibiotics are indicated in cases of rapid spread of lesions, recurrent lesions, recurrent infection within the family, facial involvement or systemic infection (cellulitis / erysipelas)

→ First line: Cefalexin (Cefovit) 25 mg/kg/dose three times daily up to 10 days or resolution (max 4 g/day).

③ If no response, consider MRSA coverage:

→ TMP/SMX syrup [40 mg/5 mL] (Resprim or Diseptyl Syrup)  0.5 ml per kg per dose twice daily for 5-7 days (max 20 mL twice daily) or infection resolved.

→ Clindamycin (Dalacin) 10 mg/kg/dose three times daily for 7 days (max 900 mg/day).

Note: Not readily available in pharmacies and kids do not tolerate the taste.

→ If age > 8 years, may also use: Doxycycline (Doxy or Doxylin) 2 mg/kg/dose twice daily for 7 days (max 200 mg/day)

④ Abscess:

→  Incision and drainage in clinic or ED.

→ After adequate I&D, antibiotics are NOT routinely needed unless there is significant surrounding cellulitis ≥ 2 cm beyond the abscess margin.

→ If antibiotics are indicated, cefalexin is first line.

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Animal Bites

① Important info:

→ Wound should be irrigated with water and cleaned with antibacterial soap.

→ Primary closure is generally avoided. Normal sutures if cosmetically sensitive area. 

→ Tetanus jab if unvaccinated or > 5 years since last dose

→ Consult local health bureau to check if patient needs rabies vaccination (especially with wild animals).

→ Note: There is a low threshold to vaccinate against rabies, even from cat and dog bites. Rabid animals roam over from neighboring territories.

→ Link here to find local bureau:

Local Health Bureau

② Prophylactic antibiotics

→ Indicated if dog bite, cat bite, human bite and especially immunosuppressed, asplenia, advanced liver disease, edema at bite site, face, hand or cartilage involvement.

→ Augmentin [400] 20 mg/kg/dose twice daily for 5 days (max 875 mg per dose)

③ Allergy/contraindications:

→ Combination therapy:

✔ TMP/Co-trimoxazole syrup [40 mg/5 mL] (Diseptyl Syrup) 0.5 ml per kg per dose twice daily for 3-5 days(max 20 mL twice daily)

✔PLUS Clindamycin (Dalacin) 10 mg/kg/dose three times daily for 5 days(max 900 mg/day)

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Acute Gastroenteritis (AGE)

① When to investigate:

→ Diarrhea lasting more than 7 days, or diarrhea in a traveler.

→ Bloody or mucousy stools or significant cramping.

② First line treatment:

→ Oral rehydration (ORS) - product called electrorice;

→ IV fluids if patients fails oral hydration and moderate to severe dehydration.

→ The vast majority of cases are viral in origin and therefore do not require antibiotic treatment.

③ Antibiotic treatment:

→ Antibiotics are recommended in the following situations:

✔ Proven pathogen in stool testing that demands treatment.  (Not all bacteria in stool need treatment.)

✔ High clinical suspicion for Shigella (bloody diarrhea, mucus, high fever)

→ First line: Azithromycin (Azenil) 10 mg/kg once daily for 3 days (max 500 mg/day)

→ Second line: Ceftriaxone (Rocephin) 50 mg/kg IM/IV once daily for 5 days (max 2 g/day)

→ Avoid anti-motility agents (e.g., loperamide/Imodium).

④ Specific infections:

→ Giardia lamblia: Metronidazole (Flagyl) 15 mg/kg/day divided into 3 doses for 5–7 days

→ Salmonella: Usually does not require antibiotics (treatment may prolong carriage). Treat only in infants under 3 months, immunocompromised patients, asplenia, IBD, or those on immunosuppressive therapy

→ Campylobacter: Azithromycin (Azenil) has been shown to shorten disease duration and reduce environmental spread if given early in illness.

→ Shigella:  Always treat, first line is Azithromycin as above. Shortens illness and fecal shedding.

→ Entamoeba histolytica:  Metronidazole(Flagyl)

→ Cryptosporidium - usually no antibiotics. Supportive care.

→ E. Coli: We do not give antibiotics for certain E. coli—specifically Shiga toxin–producing E. coli (STEC / EHEC, e.g., O157:H7)—because antibiotics increase the risk of serious complications (HUS)

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Pneumonia

① When to image:

→ Diagnosis is primarily clinical. Chest X-ray is optional. (Viral bronchiolitis can be misread as pneumonia.)

→ Imaging is recommended if diagnosis is unclear, oxygen saturation is low, significant respiratory distress, no response or clinical worsening after 48–72 hours of antibiotics, suspicion of complicated pneumonia.

② Antibiotic Considerations:

→ High clinical suspicion of bacterial pneumonia justifies antibiotic treatment, targeting Streptococcus pneumoniae.

→ Recommended treatment duration is usually 5 days, and may be extended to 7–10 days depending on the case.

③ First-line treatment:

→ Amoxicillin (Moxypen or Moxyvit) 80–90 mg/kg/day divided into 2 doses (max 1 g per dose) for 5–7 days

④ Suspected Atypical Pneumonia:

→ Azithromycin (Azenil) 10 mg/kg once daily for 3 days (max 500 mg/day)

→ Roxithromycin (Roxo) 2.5–4 mg/kg twice daily for 7 days (max 300 mg/day)

→ Clarithromycin (Karin)  7.5 mg/kg/dose twice daily for 7 days (max 1 g/day)

→ If age > 8 years: Doxycycline (Doxy or Doxylin) 2 mg/kg/dose once or twice daily for 7 days (max 200 mg/day)

⑤ Second line options for amoxicillin failure:

→ Augmentin 600 ES – 90 mg/kg/day, divided into 2 doses, for 7 days (max 2 g/dose)

→ Cefuroxime (Zinnat) 15 mg/kg/dose twice daily for 7 days (max 1 g/day)

→ Clindamycin (Dalacin) 10 mg/kg/dose three times daily for 7 days (max 900 mg/day)

Note: not readily available and taste often not tolerated.

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Group A Strep Pharyngitis / Tonsillitis

① Considerations:

→ If rapid strep positive then no need for culture just start oral antibiotics.

→ If rapid strep negative then send culture. 

→ There is no need for a repeat swab at the end of treatment.  

→ Antibiotic treatment should begin within 9 days of symptom onset.  Abx prevent rheumatic fever not glomerulonephritis.

② First line treatment:

→ Penicillin V (Rafa VK) 250 mg twice daily for 10 days (< 27 kg)

→ Penicillin V (Rafa VK) 500 mg twice daily for 10 days (≥ 27 kg)

→ Amoxicillin 50 mg/kg/day divided into 2 doses for 10 days (max 1 g/day)

③ Allergy/contraindications:

→ Cefalexin (Cefovit) 20 mg/kg/dose twice daily for 10 days (max 1 g/day)

→ Azithromycin (Azenil) 12 mg/kg once daily for 5 days (max 500 mg/day)

→ Clindamycin (Dalacin) 7 mg/kg/dose three times daily for 10 days (max 900 mg/day)

Note: not readily available and taste often not tolerated.

④ Concerning features requiring ED

→ Hot potato voice and trismus → ?peritonsillar abscess → ED for assessment & drainage. 

→ Ages 6 months to 5 years + sore throat fever + refusal to extend neck → ?retropharyngeal abscess → ED to image neck.

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Pertussis

① Considerations:

→ If there is reasonable clinical suspicion of pertussis, empirical treatment is recommended without waiting for laboratory results.

→ Classic presentation: repetitive, rapid coughing paroxysms followed by a forceful inspiratory gasp (whoop) as the patient struggles to inhale. Episodes are worse at night, may end with post-tussive vomiting and in young infants the whoop may be absent, with apnea or cyanosis instead.

→ Treatment is most effective during the highly contagious phase of the illness; within 3 weeks of cough onset.

→ The patient is considered non-infectious after 5 days of appropriate antibiotic treatment.

→ Post-exposure prophylaxis should be given to close contacts, along with PCR testing when indicated. Prophylaxis is effective if given within 3 weeks of exposure.

→ The prophylactic regimen is the same as the treatment regimen for pertussis.

② First line treatment:

→  Azithromycin 10 mg/kg (max 500 mg) on Day 1

→ Followed by Azithromycin 5 mg/kg once daily (max 250 mg) on Days 2–5 (Total duration: 5 days)

→  Infants under 6 months: Azithromycin 10 mg/kg once daily for 5 days

③ Allergy/contraindications:

→  TMP/Co-trimoxazole syrup [40 mg/5 mL] (Diseptyl Syrup) 0.5 ml /kg /dose twice daily for 14 days (max 20 mL twice daily)

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Acute Otitis Media (AOM)

① Considerations:

→ Infants older than 6 months, if the illness is not severe and not recurrent, antibiotic treatment may be deferred for 24–72 hours with appropriate follow-up.

→ Antibiotic treatment is recommended if: Marked irritability, facial asymmetry, bilateral AOM, prominent bulging of the tympanic membrane or fever > 39°C

→ No place for antibiotic drops usage

② First line antibiotics:

→ Amoxicillin (Moxypen or Moxyvit) 45 mg/kg/dose twice daily (max 2 g/day) for 7 days

③ Second line options:

→ Augmentin (600 ES) 45 mg/kg/dose twice daily (max 2 g/day) for 7 days

→ Ceftriaxone 50 mg/kg IM/IV once daily for 3 days (max 2 g/day)

④ Allergy / Contraindication:

→ Azithromycin (Azenil) 10 mg/kg/day for 3–5 days (max 500 mg/day)

→ Cefuroxime (Zinnat) 15 mg/kg/dose twice daily (max 1 g/day)

→ Clarithromycin (Karin) 7.5 mg/kg/dose twice daily (max 1 g/day)

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Otitis Externa

① First line treatment:

→ Desoren ear drops (Polumuxin + Neomycin + Dexamethasone) 3 drops x 3-4/day

→ Cetraxal ear drops (ciprofloxacin) - 3 drops x 2/day for 7 days

✔ First choice in patients with concerns for perforated tympanic membrane or AOM tympanostomy tubes

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Conjunctivitis

① First line treatment:

→ Synthomycin ointment (chloramphenicol) Apply x 3-4 / day until better. 

✔ Eye ointment best for infants & toddlers (easier to apply; less cooperation needed), bedtime dosing (overnight coverage) or when administering drops is difficult.

→ Lacromycin drops (gentamicin) 1 drop x three to four times daily until better. 

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Lower Urinary Tract Infection

① Testing:

→ If urinalysis is negative, UTI is unlikely - consider an alternative diagnosis like vaginitis or viral urethritis.

→ Urine culture should be obtained before initiating antibiotics.

→ Urine sampling method:

✔ Toilet-trained children / infant boys – midstream urine (MSU)

✔ Non–toilet-trained children / infant girls – bladder catheterization or suprapubic aspiration.

→ There is no need to repeat urinalysis after completing antibiotic treatment.

② First line antibiotics:

→  TMP/Co-trimoxazole syrup [40 mg/5 mL] (Diseptyl Syrup) 0.5ml/kg/dose twice daily for 3–5 days (max 20 mL twice daily)

→ Nitrofurantoin 5–7 mg/kg/day divided into 4 doses (max 400 mg/day) for 3–5 days

✘ Contraindicated in G6PD deficiency, eGFR < 60, and age < 2 months

→ Cefalexin (Cefovit) 15–35 mg/kg/dose three times daily for 3–5 days (max 4 g/day)

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Pinworms

① Treatment:

→ Vermox Syrup: 5ml for 2 and over and 2.5ml for age 1-2. Repeat in ten days.

→ Treat whole family if recurrent infections. 

→ Wash bed linens on a hot cycle

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Exclusion and Return to School

Streptococcal Pharyngitis

→ Infectious period: 1–3 days before symptoms

→ Return to daycare/school:

✔ ≥24 hours after starting appropriate antibiotics

✔ No fever and clinical improvement

✔ Without antibiotics → contagious up to 3 weeks

Fever ≥38°C

→ Return to daycare/school: At least 24 hours after fever resolves (without antipyretics)

Hand, Foot, and Mouth Disease

→ Infectious period: Until all blisters have dried

→ Return to daycare/school: Once all lesions are dry

Head Lice

→ Return to daycare/school: After initiation of treatment. No routine exclusion required

Impetigo

→ Infectious period: As long as lesions are oozing

→ Return to daycare/school: ≥24 hours after starting appropriate antibiotics. Lesions can be covered. 

Molluscum Contagiosum

→ Infectious period: As long as lesions are present. No exclusion required

Diarrhea

→ Exclude from the onset of the illness until no less than 24 hours after the diarrhea stops

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Do you have any other infectious diseases or clinical scenarios that you'd like to see covered?

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