Recurrent infections

Pre-referral guidelines for primary care providers

Many parents are concerned by recurrent infections in their children, generating many visits to general practitioners and many referrals to paediatric outpatient services. Generally these are simply part of routine childhood development, with most children experiencing at least six significant viral infections per year for the first six years of life, the majority of these coming in the early child care or kinder years and predominantly in winter/spring.

Certain recurrent infections (e.g. otitis media, tonsillitis, UTI) may require management in their own right - see Management below.

This guideline does not deal with the management of acute infections individually.


Recurrent infections in childhood are extremely common and do not signify an immune deficiency in most cases. The following are red flags to consider referral:

  • concurrent failure to thrive
  • recurrent deep seated skin infections
  • recurrent need for intravenous antibiotics to clear infections
  • two months of consecutive antibiotics for a bacterial infection with no improvement
  • two or more infections to sterile sites (e.g. meningitis, osteomyelitis, cellulitis, sepsis)
  • persistent thrush in children older than 1 month
  • family history of primary immune deficiency

Practice points

  • The vast majority of recurrent infections in children are a normal part of growing up - immune deficiency should be considered in the presence of any red flags (see Diagnosis above).
  • Many recurrent infections (esp. otitis media, tonsillitis and respiratory tract infections) are either over-diagnosed or over-treated, with many of these not requiring antibiotics (see Management below).
  • Ensure a child is having true UTIs with a positive urine culture (not just urinary symptoms or positive dipstick/microscopy results).
  • Encourage all children to participate in the immunisation schedule, unless medically contraindicated.


The vast majority of recurrent infections in children are a normal part of growing up. If an immune deficiency is suspected (see Diagnosis above for red flags), an FBE and film is a reasonable screen. If there is still doubt, referral to paediatric outpatient services can be undertaken.

Certain recurrent infections may require specific management:

  • Recurrent acute otitis media (AOM)
    • Ensure that AOM is truly occurring and is not being over-diagnosed (red bulging tympanic membrane with loss of light reflex, not simply injection of the membrane).
    • Check for hearing difficulties.
    • Consider ENT referral for ventilation tube insertion.
    • Consider immune deficiency if not responding to antibiotics and ventilation tubes.
  • Recurrent tonsillitis
    • Remember that the vast majority on tonsillitis in children < 5 years of age is viral and does not require antibiotic therapy.
    • Consider ENT referral if true tonsillitis (not just pharyngitis or viral URTI) occurring 6 times per year, or 5 times per year in 2 consecutive years, or 3 times per year in 3 consecutive years.
  • Recurrent respiratory tract infections
    • Almost all upper respiratory tract infections (URTIs) in children are viral, thus do not need antibiotic therapy and are a normal part of growing up for healthy children.
    • A post-viral cough is common for several weeks after URTIs and does not need treatment.
    • Many lower respiratory tract infections in younger children (e.g. bronchiolitis, pneumonitis) are viral and do not require antibiotic therapy or signify an immune problem.
    • Recurrent lobar/focal pneumonia does raise concern for immune difficulties and referral to paediatric outpatient services is warranted.
  • Recurrent urinary tract infections (UTI)
    • Ensure that the child is having true UTIs with a positive urine culture (not just urinary symptoms or positive dipstick/microscopy results)
    • Organise renal ultrasound
    • Referral to paediatric outpatient services is warranted for recurrent UTIs in infants and toddlers, if renal anomalies are present, if the UTI is not able to be cleared, or if occurring many times in older children.

Referral pathways

  • Paediatrician
    • Referral to paediatric outpatient services is appropriate when immune deficiency is suggested by the presence of red flags (above), or for recurrent UTIs or lobar pneumonias.
    • Information to bring to any appointments:
      • investigations and treatments from previous infections
      • growth charts (if available)
      • the child's Maternal and Child Health Nurse book ("green book").
  • ENT surgeon
    • Consider referral for relevant cases of recurrent otitis media and/or tonsillitis (see Management above).