Antibiotics By Diagnosis (Peds)

Bugs & Drugs

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.
Fever of Uncertain Source (FUS)	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 Ceftriaxone1 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!

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.

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.
Septic shock syndromes	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, GN-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.
Central line infection	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 ifMRSA 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
Eyes: Orbital cellulitis
Eyes: Periorbital (preseptal) cellulitis
Ears: Otitis externa
Ears: Otitis media
Mouth: Ludwig's angina
Mouth: Dental abscess
Mouth: Gingivostomatitis