Antibiotics By Diagnosis (Peds)

Neonatal Infections

NOTE: All doses listed below are for patients >2 kg and at least 7 days of age

Any infant who has tachycardia out of proportion to fever or HR >180 in any age group has a serious bacterial infection (SBI) until proven otherwise. Other serious risk factors include lethargy, hyperventiliation, cyanosis, poor perfusion and hypotonia. Have a high suspicion and treat accordingly. Always treat for meningitis until you are sure it is not. Note that bacterial etiology and antimicrobial therapies are similar for all neonatal illnesses.

Fever of Uncertain Source (FUS)	Neonatal (0-30 days): GBS, E. coli, Klebsiella, Enterobacter, Listeria or S. aureus (rare)	Send blood, urine and CSF cultures. Listeria, while infrequent at CCHMC, may sporadically occur in clustered cases. Ampicillin 200 mg/kg/day (if >2 kg) IV div Q6 AND Cefotaxime 200 mg/kg/day IV div Q6. Ampicillin 200 mg/kg/day (if >2 kg) IV div Q6 AND Gentamicin 3.5 mg/kg/day IV Q24. Consider risk factors for neonatal HSV disease. Test and treat accordingly.
	Neonatal (30-60 days): See above.	Workup: Blood and urine specimen. If low-risk (non-ill appearing), normal blood and urine analyses, parents and PMD okay, consider no LP, no antibiotics, and discharge home with f/u in 12-24 hours. Otherwise, LP + Abx. Cefotaxime 200 mg/kg/day IV div Q6 or Ceftriaxone 100 mg/kg/day IV div Q12. If evidence of UTI or severly ill infant, add Ampicillin.
Meningitis	Preterm to 60 days: GBS (49%), E. coli (18%), Listeria (7%), misc GN's, GP's	Ampicillin 400 mg/kg/day (if >2 kg) IV div Q6 (if >7 days) AND Cefotaxime 200 mg/kg/day IV div Q6 (if >7 days). Ampicillin 400 mg/kg/day (if >2 kg) IV div Q6 (if >7 days) AND Gentamicin 4 mg/kg/day IV Q24. If GBS meningitis, treat 21 days. If GN meningitis, treat 21 days (and >14 days after CSF sterilizes). Tailor therapy when specific etiology known
Neonatal HSV	HSV type 1 or 2	Risk greatest under 3 weeks of age. Greatest risk factors is primary maternal HSV at delivery. Conjunctival disease may be manifestation of SEM disease. Acyclovir 20 mg/kg/dose Q8 IV x 21 days for CNS or disseminated disease. No role for oral acyclovir for known or suspected HSV disease. Add Trifluridine ophthalmic solution Q2 hours for ocular involvement. Always refer to Ophthalmologist immediately.
Pneumonia	GBS, Listeria, coliforms, S. aureus, Pseudomonas. If AF pneumonitis: Chlamydia, syphilis. Viruses: CMV, HSV, rubella.	Ampicillin 200 mg/kg/day (if >2 kg) IV div Q6 (if >7 days) AND Cefotaxime 200 mg/kg/day IV div Q6 (if >7 days). Ampicillin 200 mg/kg/day (if >2 kg) IV div Q6 (if >7 days) AND Gentamicin 3.5 mg/kg/day IV Q24. If suspect Chlamydia (afebrile, IgM >1:8, exposure, staccato cough), add Erythromycin ethyl succinate 40 mg/kg/day PO div Q6 x 14 days. Tailor therapy when specific pathogen identified.
Osteomyelitis	Newborn period: S. aureus, GN-bacilli, GBS, Gonococcus	Often afebrile, best predictor is localizing signs. 2/3 have positive blood cultures. Surgical drainage imperative. Seek etiologic diagnosis and tailor therapy. Empirix treatment: Nafcillin 200 mg/kg/day IV div Q6 AND Cefotaxime 150 mg/kg/day IV div Q8 for >21 days. Send joint fluid for cultures and treat based on etiology identified.
UTI	GBS, GN-rods, Listeria, S. aureus	Pursue imagain as outlined in CCHMC guidelines: www.cincinnatichildrens.org/guidelines. <2 weeks: Ampicillin 100 mg/kg/day IV div Q6 (or Q12 if <7 days) AND Gentamicin 3 mg/kg/day IV Q24 OR Cefotaxime 150 mg/kg/day IV div Q8 2 weeks - 2 months: Ampicillin 100 mg/kg/day IV div Q6 AND Cefotaxime 150 mg/kg/day div Q8
Neonatal conjunctivits	Neonatal: Determine cause and treatment by number of post-delivery days to onset. Prophylaxis is Erythromycin 0.5% ointment x1 or Tetracycline 1% or Silver Nitrate 1% x1 topical, applied at birth.
	Onset 2-4 days: N. gonorrheae	Hyperpurulent. Topical treatment insufficient. Evaluate for Chlamydia. Treat mother and partners. Ceftriaxone 25-50 mg/kg IV/IM x1 (max 125 mg); cannot be used in neonates requiring calcium-containing fluids OR Cefotaxime 100 mg/kg IV/IM x1. May treat >1 day for severe cases. Always irrigate eyes with saline.
	Onset 3-10 days: C. trachomatis	Erythromycin 50 mg/kg/day x10-14 days. Treat mother and partners. 20% have concomitant pneumonia. Azithromycin 20 mg/kg/day x3 days shown to be effective.
	Onset 6-14 days: HSV	Consider if serous discharge (not mucopurulent), bulbar injection and corneal dendrites on fluorescein exam. Consult ophtho immediately!

Febrile Syndromes/Bloodstream Infections

Fever of Uncertain Source (FUS)	Infant & Child (2-36 months)	Workup: If well-appearing, and parents, MD and PMD confortable with follow up, consider no testing. If in season, consider testing for RSV, enterovirus or influenza. Urine: UTI most common serious bacterial infection in males (uncircumcised or <6 months) or females <2 years. Other risk factors include Tmax >39 or Caucasian race. Blood: CBC and blood culture only if ill-appearing or at 'high-risk' for serious bacterial infection.
Septic shock syndromes	Bacteremic: S. pneumo, N. meningitidis, Hib (if not immunized)	Replete intravascular volume, maximize delivery of oxygen to tissues. Blood cultures. Ceftriaxone 50 mg/kg/day IV/IM Q24 or Cefotaxime 150 mg/kg/day IV div Q8 until afebrile x24 hours.
	Toxic shock syndromes: Staphylococcal (less often associated with deep tissue disease), Streptococcal	Empiric therapy should include Clindamycin and ß-lactam antibiotic until etiology is isolated. Staphylococcal: Most often associated with toxin-producing organism at a mucosal site, may involved disease at a deeper site. Associated with tampon use, wound infection or burns. 5-15% case fatality rate. Rx: Nafcillin AND clindamycin as initial therapy. Can also use Cefazolin or vancomycin in place of Nafcillin if MRSA suspected. IVIG 1 g/kg may bind toxins, but should be reserved for life-threatening infections. Streptococcal: Invasive disease at a deep site is the rule; deep site infection should be sought aggressively and treated. Defined as isolation of GAS, hypotension, renal impairment, coagulopathy, ARDS and soft tissue necrosis. Associated with erisypelas, Necrotizing Fascitis, secondary infection of varicella. Rx: Once streptococcus is identified, change therapy to Pencillin or other ß-lactam antibiotic PLUS Clindamycin.
Central line infection	Coagulase-negative Staph (CONS), S. aureus, GN-bacilli, Candida spp.	Coagular-negative Staph (CONS): can try to salvage catheter with 10-14 days of therapy (vancomycin), 80% cure rate for exit site infections, 25% if deeper. If S. aureus, Gram-Negative bacilli or Candida: always remove the catheter if possible. S. aureus has a 10% exit site cure rate and 0% deeper infection cure rate if catheter left in. If septic thrombophlebitis, endocarditis, osteomyelitis or repeated positive cultures, ALWAYS remove catheter.
	TPN/Intralipids: as above and Malassezia furfur	Remove catheter and discontinue antimicrobials if possible. If Candida albicans, treat with Fluconazole 6-12 mg/kg/day IV Q24 (if >14 days old) x 28 days OR conventional Amphotericin B 1 mg/kg/day IV div Q24. If Staph epi, treat with vancomycin and discontinue intralipids. If M. furfur, treat with conventional Amphotericin B.
Fever and Neutropenia	Aerobic GNR, Strep. viridans, MRSA	Piperacillin-Tazobactam 400 mg/kg/day IV div Q6 OR Ceftzidime 150 mg/kg/day IV div Q8 OR Meropenem 60 mg/kg/day IV div Q8. Consider adding Gentamicin if persistently ill-appearing. Consider adding vancomycin if MRSA or coagulase-negative Staph suspected. Consider adding Amphotericin B 1 mg/kg/day IV Q24 if persistently febrile >5 days on antibiotics. Consider Meropenem alone or addition of Metronidazole if typhilitis suspected.
Lyme Disease	Borrelia burgdorferi	Early rash (erythema migrans), carditic, facial nerve palsy, meningitis/encephalitis, arthritis. Early localized/disseminated disease: Doxycycline 4 mg/kg/day PO div BID (if >7 yo) OR Amoxicillin 50 mg/kg/day PO (max 1.5 g/day) div TID x14-21 days. Alternative Erythromycin 30 mg/kg/day IV div Q8. Arthritis (no CNS disease): As above x28 days. Bell's Palsy: As above x21-28 days. Neuroborreliosis (CNS): ceftriaxone 75-100 mg/kg/day IV Q24 OR Pencillin G 300,000 U/kg/day IV div Q4 x14-21 days.
Rocky Mountain Spotted Fever	Rickettsia ricketsii	Suspect if fever, rash (95%), petechiae spreading from distal to central. Confirm with antibody titers. Ticks most often in Mid-Atlantic states. Treat empirically and aggressively, can be fatal. Doxycycline 4 mg/kg/day PO div BID x7-10 days (recommend for all age groups).
Ehrlichiosis	Ehrlichia chaffensis or phagocytophilum	Suspect if febrile, flu-like illness with rash in April-Sept. Leukopenia and thrombocytopenia common. 80% have positive blood smear (HGE only). Dx HME with PCR. Confirm with DFA. Commonly co-infected with B. burgdorferi. Doxycyline 4 mg/kg/day PO div BID x7 days.

CNS Infections

Meningitis	Outside neonatal period: S. pneumo, Meninococci, H. flu, Listeria (rare)	Cefotaxime 200 mg/kg/day IV div Q6 OR ceftriaxone 100 mg/kg/day IV div Q12-24. Vancomycin should be added after Gram stain if suggest pneumoncoccal etiology due to likelihood of resistant strains. If positive Gram Stain, institute focused therapy.
	Contact prophylaxis	Contacts of suspected and confirmed cases of N. meningitidis: All contacts who were in the same house for at least four hours duration should be treated. Notify Infection Control, who will contact public health to assist in treating daycare and other contacts. Children: Rifampin 10 mg/kg (max 600mg) PO Q12 x4 days; use 5 mg/kg if <1 month old Adults: Ciprofloxacin 500 mg PO x1 Pregnant women: Ceftriaxone 250mg IM x1
VP shunt infections	S. epi, S. aureus, Coliforms	Empiric therapy: Vancomycin AND Cefotaxime 200 mg/kg/day IV div Q6 OR ceftriaxone 100 mg/kg/day IV div Q12-24. Always involved neurosurgery in management. Tailor antimicrobial therapy to culture results.

Head, Eyes, Ears, Nose & Throat Infections

Head: Mastoiditis, acute	S. pneumo (22%), S. pyogenes (16%), S. aureus (7%), H. flu, P. aeruginosa	R/O meningitis. Surgical debridement as indicated. Transition to PO once clinically improved. Ampicillin-Sulbactam (Unasyn) 300 mg/kg/dau IV div Q6 OR Cefotaxime 150 mg/kg/day div Q8 OR ceftriaxone 50 mg/kg/day Q24 +/- Nafcillin 200mg/kg/day IV div Q6 OR Clindamycin 40 mg/kg/day IV div Q6 or vancomycin x21 days.
Head: Sinusitis, acute	S. pneumo (31%), H. flu (21%), M. catarrhalis (2%), GAS, anaerobes (6%), viruses (15%), S. aureus (4%)	Defined as facial tenderness lasting at least 10 days. Fluid in sinuses on imaging present in 87% of URIs, only 2% are bacterial. Amoxicillin 90 mg/kg/day x14-21 days. Augmentin, Cefuroxime or Cefdinir if recent antibiotics or chronic sinusitis.
Eyes: Conjunctivitis	Adenovirus (types 3, 7)	AKA pink eye. No treatment needed. Highly contagious. Cold artificial tears may help. NEVER treat with steroids except by an ophthalmologist!
	HSV types 1-2	Can be sight-threatening. Refer to ophthalmologist immediately! 30-50% recurrence in 2 years. Trifluridine OR idoxuridine ophthalmic solution 1 drop Q2-3 while awake x7-14 days. Vidarbine ophthalmic ointment Q3 until 1 weeks after healthing.
	S. pneumo, H. flu	Polymixin/trimethoprim ophthalmic solution 1 drop Q3 OR polymixin.bacitracin/Neosporin ophthalmic solution 1 drop Q3 x7-10 days.
Eyes: Dacryocystitis	Warm compresses and tear duct massage. No antimicrobial therapy usually needed. Oral antimicrobial therapy for more symptomatic infections.
Eyes: Orbital Cellulitis	S. pneumo', H. flu, M. catarrhalis, S. aureus, anaerobes, 'GAS. Post-trauma: Gram-Negative bacilli	Proptosis, limited EOM, chemosis, eyelid edema, pain. Complication of sinusitic. If pus present on CT, in orbit or subperiosteum, surgical drainage indicated. Ampicillin-Sulbactam (Unasyn) 300 mg/kg/day IV div Q6 OR Cefotaxime 150 mg/kg/day div Q8 OR ceftriaxone 50 mg/kg/day Q24 AND Nafcillin 200 mg/kg/day IV div Q6. If any MRSA isolated locally, add Clindamycin 40 mg/kg/day IV div Q6 OR vancomycin x10-14 days.
Eyes: Periorbital (preseptal) Cellulitis	S. pneumo, S. aureus, coagulase-negative Staph (CONS), anaerobes; H. flu now uncommon unless unvaccinated	Infection of soft tissues surrounding the eye without penetrating the orbital septum. Complication of local trauma not sinusitis. Eyelid and periorbital tissue edema without proptosis or limited EOM. If known entry site: Nafcillin 200 mg/kg/day IV div Q6 OR Cefazolin 100 mg/kg/day IV Q8 x7-10 days. If MRSA suspected, Vancomycin OR Clindamycin 40 mg/kg/day IV div Q6. Oral antistaphylococcal antibiotics for less severe infections. Periorbital swelling without cellulitis (often associated with sinusitis): Ceftriaxone 50 mg/kg/day IV Q24 OR Cefotaxime 150 mg/kg/day IV div Q8. ADD Clindamycin 40 mg/kg/day IV div Q6 for more severe infections of suspicion of MRSA. See 'Head: Sinusitis' for oral therapy options.
Ears: Otitis Externa	Pseudomonas, Enterobacteriae, Proteus.	Clean canal often. Neomycin/Polymixin B +/- hydrocortisone otic drops. Alternate: Ofloxacin or Ciprofloxacin solution. For 'swimmers ear' use VoSol (2% acetic acid) to canal. Candidal: Fluconazole 5-10 mg/kg/day PO Q24 x5-7 days.
Ears: Otitis Media	S. pneumo (50%), H. flu (20%), M. catarrhalis (15%), non-bacterial origin (33%).	Note: If >2 years, afebrile, no otalgia, borderline exam → consider symtomatic treatment or safety net antibiotic prescription (SNAP). Amoxicillin 80-90 mg/kg/day div BID or TID x10 days (<2 years) or x5 days (>2 years). Augmentin 90 mg/kg/day amoxcillin component div BID. Cefdinir (Omnicef), Cefpodoxime, Cefprozil, Cefuroxime. Zithromax (up to 40% resistance in PRSP).
Mouth: Ludwig's Angina	High risk of respiratory tract obstruction due to inflammatory edema. Penicillin G 200,000 U/kg/day div Q6 AND Clindamycin 40 mg/kg/day IV vid Q6. Consider Meropenem, Piperacillin-Tazobactam (Zosyn) OR ceftriaxone if GNR suspected.
Mouth: Dental abscess	Polymicrobial oral flora. Can progress to Ludwig's Angina.	Clindamycin 40 mg/kg/day PO/IV/IM div Q6 or Pencillin G 100,000-200,000 U/kg/day IV div Q6.
Mouth: Gingivostomatitis	Herpes simplex	Acyclovir PO 80 mg/kg/day div Q6 x7 days. For severe disease can use Acyclovir 30 mg/kg/day IV div Q8.
Throat: Bacterial tracheitis	S. aureus (MRSA), GAS, S. pneumo, H. flu.	([[Vancomycin OR Clindamycin 40 mg/kg/day div Q6) AND (Cefotaxime 150 mg/kg/day div Q8 OR ceftriaxone 50 mg/kg/day Q24). Tailor to cultures. Cefuroxime 100-150 mg/kg/day div Q8.
Throat: Epiglottitis	GAS, S. pneumo, S. aureus, H. flu (rare unless unvaccinated).	Provide airway support in OR or ICU setting in consultation with airway specialist. Cefotaxime 150 mg/kg/day div Q8 OR ceftriaxone 50 mg/kg/day Q24. ADD Clindamycin 40 mg/kg/day IV div Q6 OR vancomycin if Staph suspected.
Throat: Pharyngitis	Viral etiology most common. Group A, C, G Strep also. Infectious mononucleosis.	Culture before treating. GAS uncommon in children <3 years. Treatment decrease rheumatic fever 2.8 to 0.2%. Rx as below also for scarlet fever. Penicillin V 25-50 mg/kg/day PO div TID-QID OR Amoxicillin 50-75 mg/kg/day div BID-TID x10 days. Pencillin G Benzathine 600,000 U IM (<27 kg), 1.2 million U (>27 kg) x1. Erythromycin or Clindamycin for PCN-allergic patients.
	N. gonorrhea	Consider in adolescents. Ceftriaxone 125 mg IM x1 and Azithromycin 1 gram PO x1.
Throat: Retropharyngeal abscess	Polymicrobial: Streptococcal sp., anaerobes, Eikenella	Airway films in extension show increased prevertebral space. Consider CT to r/o abscess. Possible airway compromise or mediastinitis. Ampicillin-Sulbactam (Unasyn) 300 mg/kg/day IV div Q6 OR (Cefotaxime 150 mg/kg/day div Q8 OR ceftriaxone 50 mg/kg/day Q24) AND Clindamycin 40 mg/kg/day IV div Q6.

 

Respiratory Tract Infections

Bronchiolitis	RSV (50%), parainfluenza (25%), other viruses (20%)	RSV Prevention: Palivizumab 15 mg/kg IM monthly for 3-5 doses, beginning in Nov. Up to 5 doses: Infants and children with CLD or CHD <24 months (at start of RSV season) and requiring medical therapy, premature infants born at <32 weeks gestation, and certain infants with neuromuscular disease or congenital abnormalities of the airways. Up to 3 doses: Premature infants born at 32 to <35 weeks gestation, with at least 1 risk factor and born 3 months before or during RSV season.
Lower Respiratory Tract Infections (Pneumonia)	Wheezy, diffuse hazy infiltrate, less fever, less often ill-appearing; more likely viral; RSV, adenovirus, rhinovirus, parainfluenza, human metapneumovirus, influenza	Supportive care. If ill-appearing, treat for bacterial pneumonia.
	High fever, focal findings, lobar infiltrate; more likely bacterial; S. pneumo, H. flu, Mycoplasma, S. aureus (rare). Consider M. Tb.	Supportive care. Contact Infection Control if suspect M. Tb. Inpatient: Cefuroxime 150 mg/kg/day IV/IM div Q8 OR ceftriaxone 50 mg/kg/day IV/IM Q24 OR Cefotaxime 150 mg/kg/day IV div Q8 x10-14 days. If persistently ill, consider addition of Clindamycin 40 mg/kg/day IV div Q6 OR vancomycin. Rule-out parapneumonic effusion. Outpatient: Amoxicillin PO 90 mg/kg/day PO div BID x10-14 days with atypical coverage as indicated.
	Age 5-15 years: Mycoplasma or Chlamydia pneumoniae	If suspect atypical infection, treat with Azithromycin 10 mg/kg/day PO/IV x1, then 5 mg/kg/day PO/IV x4 days OR Erythromycin 40 mg/kg/day PO div QID x10 days.
Whooping cough	Bordatella pertussis	Dx: Pertussis DFA and culture or PCR. Recommended to treat household and daycare contacts. Avoid antitussives. Erythromycin ethyl succinate 40 mg/kg/day PO div QID x14 days (max 2000 mg/day). Note: Do not use erythromycin base, which causes excessive GI symptoms. Azithromycin (<6 months): 10 mg/kg once daily x5 days (max 500 mg). Note: Preferred agent for patients <1 month. Azithromycin (<6 months): 10 mg/kg x1 dose (max 500 mg), then 5 mg/kg once daily x4 days (max 250 mg).

 

Cardiovascular Infections

Endocarditis	Prophylaxis indications	Prosthetic cardiac valve or prosthetic material used for cardiac valve repair. Previous infectious endocarditis. Congenital heart disease (CHD) - except for the conditions listed below, antibiotic prophylaxis is no longer recommended for any other form of CHD. Unrepaired cyanotic CHD, including palliative shunts and conduits. Completely repaired CHD with prosthetic material or device, whether placed by surgery or by catheter intervenion, during the first 6 months after the procedure. Repaired CHD with residual defects at the site or adjacent to the site or a prosthetic patch or prosthetic device (which inhibit endotheliazation). Cardiac transplantation recipients who develop cardiac valvulopathy.
	Prophylaxis for oral, dental, respiratory tract or high risk patients with chronic GI/GU infections	Amoxicillin 50 mg/kg PO x1 OR Ampicillin 50 mg/kg IV x1, 30-60 minutes prior to the procedure. Allergic patients: Clindamycin 20 mg/kg PO/IV x1 OR Cephalexin 50 mg/kg PO x1 OR Azithromycin 15 mg/kg PO x1.
	Empiric therapy, native valves: S. viridnas, Enterococci, Staphylococci	By definition includes multiple positive blood cultures, new murmur of valvular insufficiency, emboli and echo evidence of vegetations. Send cultures and target therapy based on results. Vancomycin and Gentamicin pending culture results.

Gastroenterologic Infections

Diarrhea	Initial Workup: If blood diarrhea or >6 stools/day and febrile then consider stool cultures, fecal leukocytes, electrolytes. Isolation: Contact precautions for diapered or incontinent children.
	C. difficile	Suspect if blood diarrhea, cramping develop with recent antibiotic exposure. Metronidazole 30 mg/kg/day PO/IV div QID x10 days. Vancomycin 40 mg/kg/day PO div QID x10 days ONLY for Metronidazole failures.
	C. jejuni	Suspect if prominent abdominal pain. Young infants may only have bloody diarrhea. Can have immunoreactive complications such as AIDP, reactive arthritis, Reiter syndrome or erythema nodosum. Erythromycin 40 mg/kg/day PO div QID x5 days. Shortens duration of illness and prevents relapse if given early. Ciprofloxacin if >18 yo.
	E. coli O157:H7 (Enterotoxin producing, ETEC)	Suspect if bloody diarrhea, >6 unformed stools/day and afebrile. Causes 36% of bloody diarrhea. Consider CBC and blood smear. If no hemolysis, azotemia or thrombocytopenia after 3 days of illness, risk of developing HUS is low. Antimicrobial therapy may precipitate an adverse reaction.
	Salmonella	May cause asymptomatic disease, gastroenteritis, bacteremia, osteomyelitis or meningitis. Exposures to lizards and other reptiles may result in unusual species of Salmonella. Antimicrobial therapy increases duration of illness in most carriers. Therapy recommended if invasive or focal disease, if <3 months old, chronic GI disease, oncology patients, hemoglobinopathies, or HIV+. May treat with Amoxicillin or TMP-SMX; Ceftriaxone for neonates (not receiving calcium containing fluids) or septic clinical state.
	Shigella	Suspect if fever, cramps, tenesmus, abdominal pain. Complications include seizures, bacteremia, Reiter Syndrome, HUS (S. dystenteriae type 1), toxic megacolon and toxic encephalopathy (ekiri syndrome). Cefixime 8 mg/kg/day PO div BID or TMP-SMX (Bactrim) 8 mg/kg/day TMP PO div TID x5-7 days. Illness usually self-limited (48-72 hours), but treatment is always indicated to decrease duration of shedding, which is important for public health measures.
	Yersinia enterocolitica	Causes mesenteric adenitis, mimics appendicitis. Predisposed by iron overload states (chronic transfusions). Antimicrobial therapies not indicated in normal hosts.
Necrotizing Enterocolitis (NEC)	Multifactorial disease, including bacterial invasion (debated). E. coli, Klebsiella, Pseudomonas, Clostridial sp., S. aureus, B. fragilis.	Bacteremia in 30-50% of cases. Definitive antimicrobial therapy based on culture results. B. fragilis invades gut after several days of age. Ampicillin AND Gentamicin x10 or more days Consider adding Cefotaxime if CNS involvement cannot be exclused. Consider replacing Ampicillin with Vancomycin if MRSA/CONS. Consider adding Clindamycin if perforation cannot be excluded.
Peritonitis (bowel perforation or appendicitis)	Enteric GNR, Bacteroides sp., Enterococcus sp.	Meropenem 60 mg/kg/day IV div Q8 OR Piperacillin-Tazobactam 400 mg/kg/day IV div Q6 x7-10 days. Ampicillin 150 mg/kg/day IV div Q8 AND Gentamicin (dose per age) IV div Q8 AND [Clindamycin 40 mg/kg/day IV Q6 OR Metronidazole 30 mg/kg/day IV div Q6] x7-10 days.
Peritonitis (peritoneal dialysis)	Staphylococci, GNs, yeast	Antibiotic added to dialysate in concentrations approximating those attained in serum for systemic disease (Gentamicin 8 mg/L, Vancomycin 50 mg/L).

Genitourinary Infections

Pyelonephritis	Enterobacteriaceae (E. coli most common; causes perinephric abscesses), Enterococci	Inpatien't: Ceftriaxone 50 mg/kg/day IV/IM Q24 OR Genamicin (age based dosing) OR TMP/SMX (Bactrim) 8 mg/kg/day IV div BID x14 days. Treat IV until defervesces and clinically improved, then transition to PO. Outpatient: TMP-SMX (Bactrim) OR Cefixime OR Ciprofloxacin (in adolescents); see doses under UTI
UTI	E. coli (80%), Klebsiella, Proteus, Enterobacter, Pseudomonas, Enterococcus, S. saprophyticus (a CONS), GBS	Inpatient: >2 months: Cefotaxime or Ceftriaxone until taking PO, well appearing → transition to outpatient therapy. Outpatient: (Infants and Children): TMP-SMX (Bactrim) 6-10 mg/kg/day TMP component div BID OR Cefixime 16 mg/kg/day x1 day, then 8 mg/kg/day Q24 (max 400 mg/dose) OR Cephalexin 25 mg/kg/dose QID (max 1000 mg/dose) x7-14 days. Alternatives: Nitrofurantoin, Ciprofloxacin, Ceftriaxone. (Adults): Bactrim DS BID x3 days or Ciprofloxacin 250 mg BID x3 days.

Skin & Soft Tissue Infections

Skin abscess	Strep or Staph sp. (MRSA)	OSSA/MSSA - Cephalexin 50-75 mg/kg/day PO div TID OR Augmentin 80-90 mg/kg/day PO div BID x5-7 days. I&D when indicated. If MRSA prevalent or if recurrent abscess, send specimen for culture and sensitivity. Treat with Clindamycin 40 mg/kg/day IV div Q6 or TMP-SMX (Bactrim) 5 mg/kg/dose TMP Q6-8. If toxic-appearing, use Vancomycin.
Breast abscess	Neonate: Gram stain and culture expressed material/colostrum. Treat with IV abx to minimize damage to breast tissue. Empiric treatment with Nafcillin or Vancomycin (if contacts with MRSA). Non-neonate: Nafcillin 200 mg/kg/day IV div Q6 x5-7 days; Cefotaxime if GNR found on Gram stain
Cellulitis (unknown etiology)	GAS, S. aureus	Start IV: Clindamycin 40 mg/kg/day IV div Q6 if high community incidence of MRSA. May use Nafcillin 200 mg/kg/day IV div Q6 OR Cefazolin 100 mg/kg/day IV div Q8 if low incidence of MRSA. Transition to PO when stable. If no improvement, change to Vancomycin (dose by age). PO: Cephalexin 50-75 mg/kg/day divided TID OR Dicloxacillin 50 mg/kg/day PO div Q6. Total duration of treatment 7-10 days.
Erysipelas	Streptococcal	Penicillin G IV, then transition to Pencicillin V or Amoxicillin PO x10 days.
Impetigo	Mixed Strep and Staph sp. Bullous impetigo more likely Staphylococcal.	Mupirocin topical to lesions TID, cleanse with soap and water. Bathe daily. If extensive, treat with Cephalexin PO or Amoxicillin-Clavunate x5-7 days.
Omphalitis/Funisitis	Coliform bacteria, S. aureus and anaerobes (Clostridia)	Empiric: Cefotaxime AND Clindamycin x10 or more days. If MRSA prevalent, Amoxicillin, Cephalexin. Funisitis (local infection of cord): cord care, topical antimicrobials.
Paronychia	S. aureus, anaerobes	Local wound care and I&D unless signs of spreading infection, then consider Augmentin or Clindamycin.
Scabies	Sarcoptes scabeii	Topical 5% Permethrin cream, apply to neck down, wash off in 8-14 hours. Topical Lindane 1%, 1 oz lotion/30 g cream, apply to neck down, wash off in 8 hours.
Staph scaled skin syndrome	Toxin producing S. aureus	Differentiate from TENs (drug induced). Corticosteroids contraindicated. Culture skin. Nafcillin 200 mg/kg/day IV div Q6 OR Cefazolin IV x5-7 days. Consider Vancomycin. Avoid TMP-SMX.
Tinea corporis	May use one of many topical antifungal agents: Terbinafine 1% cream or gel BID to affected areas; Clotrimazole 1% cream, lotion or solution; others include Econazole, Sulconazole, Oxiconazole, Naftifine, Cicloprox, Ketoconazole, Sertaconazle, Moconazole and Tolnaftate. Treat for 14 days. Keep affected areas dry.
Tinea capitis	Trichophyton tonsurans	[Griseofulvin Microsize 10-20 mg/kg/day div Q12-24 (max 1000 mg/day) OR Griseofulfin Ultramicrosize >2 years 5-10 mg/kg/day div Q12-24 x6 weeks] AND Selenium sulfide shampoo twice weekly x1 week as directed.
Necrotizing fasciitis	Strep (A, C or G), Clostridia or polymicrobial	Prompt surgical debridement and cultures. Send for cultures and sensitivites. Treat with Clindamycin AND [Zosyn OR Cefotaxime]. For proven streptococcal disease, Penicillin and Clindamycin suffice.
Animal bites	Rabies prone: BATS, feral cats, raccoon, skunk, foxes, coyotes, most carnivores, woodchucks and livestock in certain areas	Treat all bat and feral cat exposures with both HRIG and Rabies vaccine as below. Otherwise, treat with vaccine and contact public health officials or infection control for advice on whether to treat with HRIG. Monitor animal for 10 days. Rabies vaccine 1 mL IM into deltoid days 0, 3, 7, 14 and 28. HRIG 20 IU/kg around wound and begin vaccination series with HDCV or RVA vaccine days 0, 3, 7, 14 and 28. Consider treating with Augmentin as below.
	Non Rabies-prone: Rodents, rabbits, hares, squirrels, hamsters, guinea pigs, gerbils, rats, chipmunks and mice usually do not require anti-rabies therapy. Consult public health officials with concerns. Check tetanus status. Consider Augmentin as below.
	Cat: Pasteurella multocida, S. aureus	Augmentin 45 mg/kg/day div Q8-12 x5-7 days. For PCN allergic patients, Pasteurella is covered by Doxycycline or Ciprofloxacin. Add another drug for Strep or Staph sp. Rabies: See above if feral cat. Check tetanus status.
	Dog: Pasteurella multocida, S. aureu's, Bacteroides, Fusobacterium, Capnophaga	Augmentin 45 mg/kg/day PO div Q8-12 x5-7 days Rabies: see above. Check tetanus status.
	Human: Strep viridans (100%), Staph epi (53%), Cornybacterium (41%), S. aureus (29%), Eikenella, Bacteroides, Peptostrep	High rates of infection. Do not close open wounds! Early (no signs of infection): Augmentin 45 mg/kg/day PO div Q8-12 x5-7 days. Late (signs of infection): Ampicillin-Sulbactam (Unasyn) IV. Can use Clindamycin AND Ampicillin. Check tetanus status.
	Rat or pig (polymicrobial, Sprillum minus, Streptobacillus)	Augmentin 45 mg/kg/day PO div Q8-12 x5-7 days Rabies: see above. Check tetanus status.
Lymphadenitis	Localized infection: GAS, S. aureus (MRSA)...less likely anaerobes, M. Tb (scrofula), Toxoplasmosis, Tularemia, Sporotrichosis, atypical mycobacterial (consider the latter if nonresponsive to antimicrobials)	MSSA: Augmentin 90 mg/kg/day PO div BID OR Cephalexin 100 mg/kg/day PO div QID x10 days. If IV needed, Cefazolin 100 mg/kg/day IV div Q8. MRSA: Clindamycin OR TMP-SMX OR Linezolid. If IV needed, Clindamycin 40 mg/kg/day IV div Q6 OR Vancomycin (age based dosing) x7-10 days total.
	Cat-scratch disease: Bartonella henslae	Lymphadenitis common in axillary/epitrochlear nodes (46%), neck (26%), inguinal (17%). Treat for immunocomprimised host of signs of systemic illness (HSM). Azithromycin 10 mg/kg/day PO Q24 x5 days. May also use Bactrim, Rifampin and Ciprofloxacin. Duration of therapy is uncertain.

 

Orthopedic Infections

Osteomyelitis	Outside neonatal period: S. aureus, GAS, rarely coliforms	Nafcillin 200 mg/kg/day IV div Q6 OR Cefazolin 100 mg/kg/day div Q8 x4-6 weeks or longer. If open fracture with trauma, consider adding anti-Pseudomonal coverage pending negative cultures for GNs. If nonresponsive to above therapy or very ill, consider Vancomycin or Clindamycin if MRSA present.
Septic arthritis	Outside neonatal period: S. aureus, GAS (S. pneumo and Hib unlikely if fully immunized). Kingella if <5 yo. Gonococcus in adolescents.	Treatment requires adequate drainage of purulent joint fluid. Involved orthopedics early. If immunized against Hib: Nafcillin 200 mg/kg/day IV div Q6 OR Cefazolin 100 mg/kg/day div Q8 x21 days. If unimmunized again Hib: Cefuroxime OR [Cefotaxime AND [Nafcillin OR Cefazolin]] x21 days. If Gonococcus suspected or isolated, Ceftriaxone 50 mg/kg/day IV/IM daily OR Penicillin G IV (if susceptible) x7-10 days.

See Also

• Antibiotics (Main)
• Pediatric Fever

A Note On Ceftriaxone

CAUTION: Ceftriaxone (Rocephin) should NOT be administered to any patient who is less that 28 days of age. If a 3rd generation cephalosporin is required, please consider using Cefotaxime instead.

Source

Cincinnati Children's Hospital "The Pocket" 2010-2011