Antibiotics By Diagnosis (Peds): Difference between revisions
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== Neonatal Infections<br>  ==
#REDIRECT[[Pediatric antibiotics]]
 
NOTE: All doses listed below are for patients &gt;2 kg and at least 7 days of age<br>
 
Any infant who has '''tachycardia out of proportion''' to fever or HR &gt;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.<br>
 
{| cellspacing="0" cellpadding="2" border="1" align="left"
|-
| rowspan="2" | Fever of Uncertain Source (FUS)
| valign="top" align="left" |
Neonatal (0-30 days): ''GBS, E. coli, Klebsiella, Enterobacter, Listeria or S. aureus'' (rare)<br>
 
|
Send blood, urine and CSF cultures. ''Listeria'', while infrequent at CCHMC, may sporadically occur in clustered cases.
 
#Ampicillin 200 mg/kg/day (if &gt;2 kg) IV div Q6 AND Cefotaxime 200 mg/kg/day IV div Q6.
#Ampicillin 200 mg/kg/day (if &gt;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.<br>
 
|-
| Neonatal (30-60 days): See above.<br>
|
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.<br>
 
|-
| Meningitis<br>
| Preterm to 60 days: ''GBS'' (49%), ''E. coli ''(18%), ''Listeria ''(7%), ''misc GN's'', ''GP's''<br>
|
#Ampicillin 400 mg/kg/day (if &gt;2 kg) IV div Q6 (if &gt;7 days) AND Cefotaxime 200 mg/kg/day IV div Q6 (if &gt;7 days).<br>
#Ampicillin 400 mg/kg/day (if &gt;2 kg) IV div Q6 (if &gt;7 days) AND Gentamicin 4 mg/kg/day IV Q24.<br>
 
If ''GBS'' meningitis, treat 21 days. If ''GN'' meningitis, treat 21 days (and &gt;14 days after CSF sterilizes). Tailor therapy when specific etiology known
 
|-
| Neonatal HSV<br>
| HSV type 1 or 2<br>
|
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<br>
| ''GBS, Listeria, coliforms, S. aureus, Pseudomonas. ''If AF pneumonitis: ''Chlamydia,&nbsp;''syphilis. Viruses: CMV, HSV, rubella.<br>
|
#Ampicillin 200 mg/kg/day (if &gt;2 kg) IV div Q6 (if &gt;7 days) AND Cefotaxime 200 mg/kg/day IV div Q6 (if &gt;7 days).<br>
#Ampicillin 200 mg/kg/day (if &gt;2 kg) IV div Q6 (if &gt;7 days) AND Gentamicin 3.5 mg/kg/day IV Q24.
#If suspect ''Chlamydia'' (afebrile, IgM &gt;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<br>
| Newborn period: ''S. aureus, GN-bacilli, GBS, Gonococcus''<br>
|
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 &gt;21 days.
 
Send joint fluid for cultures and treat based on etiology identified.
 
|-
| UTI<br>
| ''GBS, GN-rods, Listeria, S. aureus''<br>
|
Pursue imagain as outlined in CCHMC guidelines: www.cincinnatichildrens.org/guidelines.
 
&lt;2 weeks: Ampicillin 100 mg/kg/day IV div Q6 (or Q12 if &lt;7 days) AND Gentamicin 3 mg/kg/day IV Q24 OR Cefotaxime 150 mg/kg/day IV div Q8<br>
 
2 weeks - 2 months: Ampicillin 100 mg/kg/day IV div Q6 AND Cefotaxime 150 mg/kg/day div Q8<br>
 
|-
| rowspan="4" | Neonatal conjunctivits<br>
| colspan="2" |
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''<br>
|
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 &gt;1 day for severe cases. Always irrigate eyes with saline.
 
|-
| Onset 3-10 days: ''C. trachomatis<br>''
|
#Erythromycin 50 mg/kg/day x10-14 days. Treat mother and partners. 20% have concomitant pneumonia.<br>
#Azithromycin 20 mg/kg/day x3 days shown to be effective.
 
|-
| Onset 6-14 days: HSV<br>
| Consider if serous discharge (not mucopurulent), bulbar injection and corneal dendrites on fluorescein exam. Consult ophtho immediately!
|}
 
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== Febrile Syndromes/Bloodstream Infections<br>  ==
 
{| cellspacing="0" cellpadding="2" border="1" align="left"
|-
| Fever of Uncertain Source (FUS)
| Infant &amp; 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 &lt;6 months) or females &lt;2 years. Other risk factors include Tmax &gt;39 or Caucasian race.
 
Blood: CBC and [[blood culture]] only if ill-appearing or at 'high-risk' for serious bacterial infection.
 
|-
| rowspan="2" | Septic shock syndromes
| Bacteremic: ''S. pneumo, N. meningitidis, Hib'' (if not immunized)
| rowspan="1" | 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''
| rowspan="1" |
'''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.
 
|-
| rowspan="2" | Central line infection
| ''Coagulase-negative Staph (CONS), S. aureus, GN-bacilli, Candida spp.''
| rowspan="1" |
''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''
| rowspan="1" | Remove catheter and discontinue antimicrobials if possible. If ''Candida albicans'', treat with Fluconazole 6-12 mg/kg/day IV Q24 (if &gt;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 &gt;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 &gt;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.<br>
*[[Bell's Palsy]]: As above x21-28 days.<br>
*Neuroborreliosis (CNS): [[ceftriaxone]] 75-100 mg/kg/day IV Q24 OR Pencillin G 300,000 U/kg/day IV div Q4 x14-21 days.<br>
 
|-
| [[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).<br>
 
|-
| [[Ehrlichiosis]]
| ''Ehrlichia chaffensis ''or ''phagocytophilum''<br>
|
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<u></u>''.
 
#Doxycyline 4 mg/kg/day PO div BID x7 days.<br>
 
|}
 
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== CNS Infections ==
 
{| cellspacing="0" cellpadding="2" border="1" align="left"
|-
| rowspan="2" | [[Meningitis]]
| Outside neonatal period: ''S. pneumo, Meninococci, H. flu, Listeria ''(rare)<br>
| rowspan="1" |
#Cefotaxime 200 mg/kg/day IV div Q6 OR [[ceftriaxone]] 100 mg/kg/day IV div Q12-24.<br>
#[[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
| rowspan="1" |
''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 &lt;1 month old
#Adults: Ciprofloxacin 500 mg PO x1
#Pregnant women: [[Ceftriaxone]] 250mg IM x1
 
|-
| VP shunt infections
| ''S. epi, S. aureus, Coliforms''<br>
| 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.<br>
|}
 
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== Head, Eyes, Ears, Nose &amp; Throat Infections<br>  ==
 
{| cellspacing="0" cellpadding="2" border="1" align="left"
|-
| 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&nbsp;''(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.<br>
#Augmentin, Cefuroxime or Cefdinir if recent antibiotics or chronic sinusitis.
 
|-
| rowspan="3" | 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 ]]
| colspan="2" | 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 Cellulitis|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&nbsp;''(20%), ''M. catarrhalis'' (15%), non-bacterial origin (33%).
|
'''Note: '''If &gt;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 (&lt;2 years) or x5 days (&gt;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]]
| colspan="2" |
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.
 
|-
| rowspan="2" | Throat: [[Pharyngitis]]
| Viral etiology most common. Group A, C, G Strep also. Infectious mononucleosis.
| rowspan="1" |
Culture before treating. ''GAS'' uncommon in children &lt;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 (&lt;27 kg), 1.2 million U (&gt;27 kg) x1.
#Erythromycin or Clindamycin for PCN-allergic patients.
 
|-
| ''[[N. gonorrhea]]''
| rowspan="1" | 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.
|}
 
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&nbsp;
 
== Respiratory Tract Infections  ==
 
{| cellspacing="0" cellpadding="2" border="1" align="left"
|-
| [[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 &lt;24 months (at start of RSV season) and requiring medical therapy, premature infants born at &lt;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 &lt;35 weeks gestation, with at least 1 risk factor and born 3 months before or during RSV season.
 
|-
| rowspan="3" | 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
| rowspan="1" | 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.''
| rowspan="1" |
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''
| rowspan="1" | 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 (&lt;6 months): 10 mg/kg once daily x5 days (max 500 mg). Note: Preferred agent for patients &lt;1 month.
#Azithromycin (&lt;6 months): 10 mg/kg x1 dose (max 500 mg), then 5 mg/kg once daily x4 days (max 250 mg).
 
|}
 
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&nbsp;
 
== Cardiovascular Infections  ==
 
{| cellspacing="0" cellpadding="2" border="1" align="left"
|-
| rowspan="3" | Endocarditis
| '''Prophylaxis indications'''
| rowspan="1" |
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
| rowspan="1" |
#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''
| rowspan="1" | 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.
|}
 
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== Gastroenterologic Infections  ==
 
{| cellspacing="0" cellpadding="2" border="1" align="left"
|-
| rowspan="7" | Diarrhea<br>
| colspan="2" |
'''Initial Workup:''' If blood diarrhea or &gt;6 stools/day and febrile then consider stool cultures, fecal leukocytes, electrolytes.
 
'''Isolation:''' Contact precautions for diapered or incontinent children.
 
|-
| ''C. difficile''<br>
|
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&nbsp;div QID x10 days ONLY for Metronidazole failures.
 
|-
| ''C. jejuni''<br>
|
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 &gt;18 yo.
 
|-
|
''E. coli O157:H7''
 
''(Enterotoxin producing, ETEC)''
 
| Suspect if bloody diarrhea, &gt;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.<br>
|-
| ''Salmonella''<br>
|
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.<br>
#Therapy recommended if invasive or focal disease, if &lt;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.<br>
 
|-
| ''Shigella''<br>
|
Suspect if fever, cramps, tenesmus, abdominal pain. Complications include seizures, bacteremia, Reiter Syndrome, HUS (''S. dystenteriae&nbsp;''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.<br>
 
|-
| ''Yersinia enterocolitica''<br>
| Causes mesenteric adenitis, mimics appendicitis. Predisposed by iron overload states (chronic transfusions). Antimicrobial therapies not indicated in normal hosts.<br>
|-
| Necrotizing Enterocolitis (NEC)<br>
| Multifactorial disease, including bacterial invasion (debated). ''E. coli, Klebsiella, Pseudomonas, Clostridial sp., S. aureus, B. fragilis.''<br>
|
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<br>
 
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.<br>
 
|-
| Peritonitis (bowel perforation or appendicitis)<br>
| ''Enteric GNR, Bacteroides sp., Enterococcus sp.''<br>
|
#Meropenem 60 mg/kg/day IV div Q8 OR Piperacillin-Tazobactam 400 mg/kg/day IV div Q6 x7-10 days.<br>
#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.<br>
 
|-
| Peritonitis (peritoneal dialysis)<br>
| ''Staphylococci, GNs, ''yeast<br>
| Antibiotic added to dialysate in concentrations approximating those attained in serum for systemic disease (Gentamicin 8 mg/L, Vancomycin 50 mg/L).<br>
|}
 
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== Genitourinary Infections<br>  ==
 
{| cellspacing="0" cellpadding="2" border="1" align="left"
|-
| Pyelonephritis<br>
| ''Enterobacteriaceae (E. coli ''most common; causes perinephric abscesses), ''Enterococci''<br>
|
'''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.'''<br>''
 
'''Outpatient: '''TMP-SMX (Bactrim) OR Cefixime OR Ciprofloxacin (in adolescents); see doses under UTI<br>
 
|-
| UTI<br>
| ''E. coli ''(80%), ''Klebsiella, Proteus, Enterobacter, Pseudomonas, Enterococcus, S. saprophyticus&nbsp;''(a CONS), ''GBS''<br>
|
'''Inpatient: '''&gt;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.<br>
 
|}
 
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== Skin &amp; Soft Tissue Infections<br>  ==
 
{| cellspacing="0" cellpadding="2" border="1" align="left"
|-
| Skin abscess<br>
| ''Strep ''or ''Staph sp. (MRSA)''<br>
|
#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&amp;D when indicated.'''<br>
#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.<br>
 
|-
| Breast abscess<br>
| colspan="2" |
#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).<br>
#Non-neonate: Nafcillin 200 mg/kg/day IV div Q6 x5-7 days; Cefotaxime if GNR found on Gram stain
 
|-
| Cellulitis (unknown etiology)<br>
| ''GAS, S. aureus''<br>
|
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<br>
| ''Streptococcal''<br>
| Penicillin G IV, then transition to Pencicillin V or Amoxicillin PO&nbsp;x10 days.<br>
|-
| Impetigo<br>
| Mixed ''Strep&nbsp;''and ''Staph sp. ''Bullous impetigo more likely ''Staphylococcal.''<br>
| Mupirocin topical to lesions TID, cleanse with soap and water. Bathe daily. If extensive, treat with [[Cephalexin]] PO or Amoxicillin-Clavunate x5-7 days.<br>
|-
| Omphalitis/Funisitis<br>
| Coliform bacteria, ''S. aureus'' and anaerobes ''(Clostridia)''<br>
|
Empiric: Cefotaxime AND Clindamycin x10 or more days. If MRSA prevalent, Amoxicillin, [[Cephalexin]].
 
Funisitis (local infection of cord): cord care, topical antimicrobials.
 
|-
| Paronychia<br>
| ''S. aureus, ''anaerobes<br>
| Local wound care and I&amp;D unless signs of spreading infection, then consider Augmentin or Clindamycin.<br>
|-
| Scabies<br>
| ''Sarcoptes scabeii''<br>
|
#Topical 5% Permethrin cream, apply to neck down, wash off in 8-14 hours.<br>
#Topical Lindane 1%, 1 oz lotion/30 g cream, apply to neck down, wash off in 8 hours.
 
|-
| Staph scaled skin syndrome<br>
| Toxin producing ''S. aureus''<br>
|
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<br>
| colspan="2" | 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.<br>
|-
| Tinea capitis<br>
| ''Trichophyton tonsurans''<br>
| [Griseofulvin Microsize 10-20 mg/kg/day div Q12-24 (max 1000 mg/day) OR Griseofulfin Ultramicrosize &gt;2 years 5-10 mg/kg/day div Q12-24 x6 weeks] AND Selenium sulfide shampoo twice weekly x1 week as directed.<br>
|-
| Necrotizing fasciitis<br>
| ''Strep (A, C ''or ''G), Clostridia ''or polymicrobial<br>
|
#Prompt surgical debridement and cultures. Send for cultures and sensitivites.<br>
#Treat with Clindamycin AND [Zosyn OR Cefotaxime]. For proven streptococcal disease, Penicillin and Clindamycin suffice.
 
|-
| rowspan="6" | Animal bites<br>
| '''Rabies prone: BATS''', feral cats, raccoon, skunk, foxes, coyotes, most carnivores, woodchucks and livestock in certain areas<br>
|
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&nbsp;IM into deltoid days 0, 3, 7, 14 and 28.
#HRIG 20 IU/kg around wound and begin vaccination series with HDCV or&nbsp;RVA vaccine days 0, 3, 7, 14 and 28.
#Consider treating with Augmentin as below.
 
|-
| colspan="2" | '''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.<br>
|-
| Cat: ''Pasteurella multocida, S. aureus''<br>
|
#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&nbsp;''or ''Staph sp.''<br>
#Rabies: See above if feral cat. Check tetanus status.
 
|-
| Dog: ''Pasteurella multocida, S. aureu''''s, Bacteroides, Fusobacterium, Capnophaga'''''<b><br></b>
|
#Augmentin 45 mg/kg/day PO div Q8-12 x5-7 days<br>
#Rabies: see above. Check tetanus status.
 
|-
| Human: ''Strep viridans&nbsp;''(100%), ''Staph epi ''(53%), ''Cornybacterium ''(41%), ''S. aureus ''(29%), ''Eikenella, Bacteroides, Peptostrep''<br>
|
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)&nbsp;IV. Can use Clindamycin AND Ampicillin.
#Check tetanus status.
 
|-
| Rat or pig (polymicrobial, ''Sprillum minus'', ''Streptobacillus'')<br>
|
#Augmentin 45 mg/kg/day PO div Q8-12 x5-7 days<br>
#Rabies: see above. Check tetanus status.
 
|-
| rowspan="2" | Lymphadenitis<br>
| Localized infection: ''GAS, S. aureus (MRSA)...less likely anaerobes, M. Tb ''(scrofula), ''Toxoplasmosis, Tularemia, Sporotrichosis,&nbsp;''atypical mycobacterial (consider the latter if nonresponsive to antimicrobials)<br>
|
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''<br>
|
Lymphadenitis common in axillary/epitrochlear nodes (46%), neck (26%), inguinal (17%). Treat for immunocomprimised host of signs of systemic illness&nbsp;(HSM).
 
#Azithromycin 10 mg/kg/day PO Q24 x5 days.
 
May also use Bactrim, Rifampin and Ciprofloxacin. Duration of therapy is uncertain.
 
|}
 
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&nbsp;
 
== Orthopedic Infections  ==
 
{| cellspacing="0" cellpadding="2" border="1" align="left"
|-
| 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 &lt;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.
 
|}
 
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==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. <br>
 
== Source==
Cincinnati Children's Hospital "The Pocket" 2010-2011
 
[[Category:Peds]] [[Category:ID]]

Latest revision as of 18:41, 25 May 2015

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