It is crucial that antibiotics should be prescribed only when they are necessary for treatment following a clear diagnosis and that these be administered for the desirable, precise duration.
While choosing an antibiotic, the age of the child, his hepatic and renal status, history of allergy, comorbid condition; antibiotic sensitivity or resistance pattern of organisms in the local community or institution, culture sensitivity findings in the patients sample (if available) and the known effectiveness, limitations and potential adverse effects of the proposed antibiotic should be duly taken into account. As far as possible, a first-line simple antibiotic, which would suffice, should be chosen for treatment instead of the strong second-line one. In the event of hypersensitivity to the first-line antibiotic or lack of proper clinical response, suitable alternative second-line antibiotic may be employed.
Taking into consideration different important factors and the recommendations of various national and international regulatory bodies, guidelines for antimicrobial therapy in children have been described in this and following sections.
Note:For dosage, mode of use and other information regarding recommended drugs, see under the individual drug in “Pediatric Drug Formulary”.
SKIN AND SOFT TISSUE INFECTIONS
Cellulitis and Erysipelas (Nonpurulent)
(Mainly Group A Streptococcus, Staphylococcus aureus; in immunocompromised—Pseudomonas aeruginosa, Haemophilus influenzae type b, and others).4
Mild
Clindamycin or cephalosporin or cloxacillin per oral (PO).
Moderate
Ceftriaxone or cefazolin or clindamycin intravenous (IV).
Severe
Empirical: Vancomycin + piperacillin − tazobactam IV
Subsequently as per culture findings:
- Monomicrobial Streptococcus pyogenes; or clostridia species:
- Penicillin + clindamycin
- Vibrio vulnificus
- Doxycycline + ceftazidime
- Polymicrobial
- Vancomycin + piperacillin − tazobactam.
Duration of treatment: 10 days
Cellulitis, Buccal
H. influenzae type b, Pneumococcus:
- Initial: Cefotaxime or ceftriaxone or cefuroxime IV/intramuscular (IM)
- Alternative: Chloramphenicol IV
- Later: Amoxicillin-clavulanate PO or a second or third generation cephalosporin PO
- Duration of treatment: 7–10 days.
BITES
Dog, Cat, Other Animals, and Human
[Streptococci, S. aureus, S. epidermidis, Pasteurella multocida and canis (in animal bites), and Eikenella corrodens (in human bites)]
Amoxicillin-clavulanate PO
Alternative: Ampicillin + clindamycin IV.
For penicillin allergic patients: clindamycin + sulfamethoxazole.
Ludwig's Angina (Bilateral Submandibular Space Infection)
(Streptococcus species, anaerobes, Eikenella corrodens, and others)
- Clindamycin or ticarcillin-clavulanate IV or
- Piperacillin-tazobactam IV.
Pyoderma, Cervical Adenitis
(Streptococcal, Staph. aureus)
Cephalexin or cloxacillin PO × 5–10 days.
For serious infection: Cloxacillin or clindamycin IV.
Rat-bite Fever
(Streptobacillus moniliformis and Spirillum minus)
Penicillin G IV or procaine penicillin IM × 7–10 days, alternatives: Tetracycline, doxycycline, gentamicin, or streptomycin (in penicillin allergic patients).
Staphylococcal Scalded Skin Syndrome
- Initial: Cloxacillin or nafcillin; vancomycin [if methicillin-resistant Staphylococcus aureus (MRSA)] PO/IV
- Later: Add clindamycin.
OROPHARYNGEAL, NOSE, EAR, EYE, AND UPPER RESPIRATORY TRACT INFECTIONS
Pharyngitis, Tonsillopharyngitis
[(Group A β-hemolytic Streptococcus (GABHS)]
- For patients who are not allergic to penicillin:
- For penicillin allergic patients:
- Erythromycin ethylsuccinate 40 mg/kg/day (max 1 g) div. in BID × 10 days PO
- Azithromycin (12 mg/kg/day × 1 day; then 6 mg/kg/day div. in OD × 4 days PO
- Clarithromycin 15 mg/kg/day (max 500 mg/day) div. in BID × 10 days PO.
- For those with only type 1 allergy to patients:
- Cefaclor 20−40 mg/kg/day (max 1.8 g/day) div. in TID × 10 days PO
- Cephalexin: 50 mg/kg/day div in q 6–8 hr PO × 10 days.
- For recurrent GABHS culture positive pharyngitis and streptococcal carriers:
- Clindamycin 20 mg/kg/day div in TID PO × 10 days; (adults—150−450 mg/dose q TID PO)
- Alternative: Amoxicillin-clavulanate @ amoxicillin 40 mg/kg/day up to 2000 mg/day div in TID × 10 days.
Retropharyngeal Cellulitis or Abscess
(Group A Streptococcus, oral anaerobes, staphylococci, H. influenzae, and Klebsiella)
Clindamycin or ampicillin-sulbactam + cefotaxime or ceftriaxone IV × several days; when improved PO (clindamycin + cefdinir or cefpodoxime).
Gingivostomatitis
(Herpetic)
Acyclovir × 7 days; for mild infection—PO; for severe cases—IV.
Diphtheria
- Or Procaine penicillin: <10 kg: 300,000 units/dose OD IM × 14 days>10 kg: 600,000 units/dose OD 1M × 14 days
- Or Aqueous crystalline penicillin 100,000–150,000 U/kg/day. div q 6 hr IV/IM × 14 days.
PLUS diphtheria antitoxin (see under “immunoglobulins and antitoxins” for dosage). Antitoxin is the mainstay of therapy.
Note:Parenteral penicillin is recommended till the patient is unable to swallow. It is followed by oral erythromycin (total duration 14 days).
Otitis Media (Acute)
Initial Treatment
- Amoxicillin 40–90 mg/kg/day div q BID × 7–10 days
- or amoxicillin clavulanate (amoxicillin 40–90 mg/kg/day) div q BID × 7–10 days
- or ceftriaxone 50 mg/kg IM/IV × 3 doses on alternate days
If patient allergic to penicillin:
- Cefdinir 14 mg/kg/day div in OD/BID × 7–10 days
- Or cefuroxime 30 mg/kg/day div in BID × 7–10 days
- Or cefpodoxime 10 mg/kg/day div in BID × 7–10 days
- Or ceftriaxone 50 mg/kg IM/IV × 3 doses on alternate days.
Antibiotic Treatment after 48–72 hours of Failure of Initial Treatment
Clindamycin 30–40 mg/kg/day div. in TID + cefuroxime or cefdinir.
Sinusitis (Acute)
(Pneumococcus, H. influenzae, Moraxella catarrhalis, streptococci)
- Uncomplicated mild/moderate acute bacterial sinusitis
- Severe sinusitis; no response to initial 3 days treatment; children age <2 years:
- Amoxicillin clavulanate high dose 80–90 mg/kg/day div in BID
- Or ceftriaxone 75 mg/kg/day IV/IM initial followed by oral cefdinir or cefuroxime
- Duration of treatment: Minimum 10 days or 7 days after resolution of symptoms
Note: Azithromycin and cotrimoxazole are not recommended (high microbial resistance)
Mastoiditis (Acute)
(Pneumococcus, group A Streptococcus, nontypable H. influenzae, Pseudomonas aeruginosa)
Obtain cultures and treat accordingly:
- Initial: Ceftriaxone 75 mg/kg/day + cloxacillin 75 mg/kg/day
- Later: As per culture and sensitivity findings.
Orbital Cellulitis
(H. influenzae, S. aureus, MRSA, S. pneumoniae, streptococci)
- Vancomycin + cefotaxime or ceftriaxone
- Add metronidazole if anaerobes suspected
- If no improvement, sinus drainage.
LOWER RESPIRATORY TRACT INFECTIONS
Epiglottitis
(H. influenzae type b in nonvaccinated children; streptococci, nontypable H. influenzae, S. aureus)
- Initial: Ceftriaxone or cefotaxime or meropenem IV × 10 days
Tracheitis Bacterial
(S. aureus, S. pneumoniae, S. pyogenes, Moraxella catarrhalis, H. influenzae, anaerobes)
- Cloxacillin or clindamycin + cefotaxime or ceftriaxone IV
- If MRSA infection—use vancomycin in place of cloxacillin or clindamycin.
Bronchitis (Acute)
(Bacterial)
Same drugs as for acute otitis media.
Pneumonia
Community-acquired Pneumonia
- Common causative organisms:
- Bacteria: Strep. pneumoniae, H. influenzae, S. aureus, Group A Streptococcus, Klebsiella, and Escherichia coli
- Viruses: Respiratory syncytial virus (RSV), parainfluenza, rhinoviruses and adenoviruses
- Nonviral pathogens: Mycoplasma pneumoniae, Chlamydia pneumoniae, and Chlamydia trachomatis
- Age incidence: Viral infections are common below 5 years of age; S. pneumoniae, M. pneumoniae, and C. pneumoniae are more common in above 5 year olds; gram-negative organisms (esp. Klebsiella, E. coli, and C. trachomatis) are common between 3 weeks and 3 months of age.
- Guide to antibiotic therapy: In view of the uncertain differentiation on clinical, radiologic, or laboratory findings between pneumonia caused by various bacterial, viral, and nonviral pathogens, antibiotic treatment is largely empirical. The choice of drugs is initially guided by the child's age and the likelihood of causative organisms in that age group, type of infection then prevalent in the community and its antibiotic sensitivity pattern, the child's immunity and nutritional status, the type of infection likely to be present in association with the underlying illness* (Table 1.1) (if any) and the severity of illness.10
- Outpatient treatment for mild illness:Initial: (i) Amoxicillin 40–50 mg/kg/day PO div q 8 h PO × 5 days
- If poor response to (i) or if high incidence of penicillin-resistant pneumococci in the community: Amoxicillin high dose (80–90 mg/kg/day) PO
- Alternative: Cefuroxime axetil or amoxicillin-clavulanate or cefdinir or cefpodoxime.
- Children >5 years, suspected M. pneumoniae, or C. pneumoniae infection:
- A macrolide (azithromycin 10 mg/kg/day OD × 5 days or clarithromycin 15 mg/kg/day div q BID × 10 days)
- Alternative in adolescents: Levofloxacin or moxifloxacin.
- Initial choice of antibiotics in severe pneumonia:
- Under 2 months of age:
- Cefotaxime or ceftriaxone IV + gentamicin IV × 10 days
- Above 2 months of age:
- Ampicillin 200 mg/kg/day div q 6 h IV + gentamicin 7.5 mg/kg/day IV/IM OD × 7–10 days
- If no response in 2 days, assess for complications, such as empyema;11
- If none: Change ampicillin to cefotaxime 200 mg/kg/day div q 6 h IV or ceftriaxone 75–100 mg/kg/day div q 12 h IV + continue gentamicin.
- Above 5 years of age:
- Cefuroxime or ceftriaxone or cefotaxime IV + macrolide (macrolide to cover against Mycoplasma and C. pneumoniae infection instead of aminoglycoside)
- Suspected S. aureus infection
- Add cloxacillin or clindamycin to initial regime of cefotaxime or ceftriaxone + gentamicin
- If suspected methicillin resistance, add vancomycin or teicoplanin or linezolid to initial regime
- Vancomycin 25–30 mg/kg IV loading dose, followed by 15–20 mg/kg/day div q 8–12 h IV
- or teicoplanin 10 mg/kg/dose q 12 h × 3 doses then 10 mg/kg/day IM or IV (bolus or slow infusion)
- or linezolid 20 mg/kg/day div q 12 h IV
- Total duration of treatment 3–4 weeks
- Multidrug resistant S. pneumoniae
- Vancomycin and linezolid
- Klebsiella pneumoniae
- Cefotaxime or ceftriaxone IV
- Mode and duration of drug administration: In patients with severe pneumonia, antibiotics should be given intravenously for first 7 days or so. Once the child improves, is stable and can take orally, treatment can be switched over to oral amoxicillin-clavulanate (in cases of infection by organisms sensitive to it). While some authorities consider this drug to be preferable to oral cephalosporins cefdinir, cefpodoxime, and cefuroxime-axetil, others consider them to be equally good. Alternatively, ceftriaxone IM can be given as a follow-up drug.
In general, antibiotics are administered for 10–14 days or till 5 days after subsidence of fever. Patients with pneumonia caused by staphylococci, gram-negative bacilli and M. pneumoniae and some cases of severe pneumonia of undiagnosed etiology need treatment for 2–3 weeks, while those due to C. pneumoniae need treatment for up to 6 weeks.12
Hospital-acquired Pneumonia
Empirical therapy:
According to prevalence and sensitivity of causative organisms in hospital/ICU:
- Potential pathogens: Pseudomonas aeruginosa, Klebsiella pneumoniae (ESBL) or Acinetobacter speciesAntibiotics: Piperacillin-tazobactam PLUS
- Aminoglycoside (amikacin, gentamicin or tobramycin) or
- Antipseudomonal fluoroquinolone (ciprofloxacin or levofloxacin)
- Methicillin resistant staphylococciFirst-line antibiotics: Vancomycin or linezolidSecond line: Daptomycin
- AnaerobesAntibiotic: Metronidazole or clindamycin
- CytomegalovirusAntibiotic: Ganciclovir IV (+ IV immunoglobulin)
- Pneumocystis cariniiAntibiotic: Trimethoprim–sulfamethoxazole
- LegionellaAntibiotic: Erythromycin
- Herpes simplexAntibiotic: Acyclovir and foscarnet IV
- Respiratory syncytial virusAntibiotic: Ribavirin by aerosol.
Empyema
- Initial: Cloxacillin + cefotaxime or ceftriaxone
- Suspected staphylococcal infection: Vancomycin + cefotaxime or ceftriaxone
- Suspected anaerobic infection: IV clindamycin
- Subsequently: As per in vitro sensitivity of the organisms grown on pus culture.
Lung Abscess or Necrotizing Pneumonia
Ceftriaxone or cefotaxime + cloxacillin or clindamycin.
Pertussis
- Erythromycin: 40–50 mg/kg div q 6 h × 14 days
- Age above 2 months: Alternatives—clarithromycin × 7 days or azithromycin × 5 days.
Tuberculosis
See in separate section on “Tuberculosis”.
INFECTIONS OF CENTRAL NERVOUS SYSTEM
Meningitis (Bacterial)
0–2 months (>2 kg)
Initial empiric therapy
- First-line therapy
- Inj. cefotaxime 50 mg/kg/dose IV–age < 7 days: q 12 hr; age > 7 days: q 8 hr; for 2–3 weeksPLUS
- Inj. gentamicin 5 mg/kg/dose IV age <7 days q 24 hr; × 2–3 weeks, age >7 days: 2.5 mg/kg/dose q 8 hr × 2–3 weeks
- Second-line therapy
- Meropenem 20 mg/kg/dose; age <7 days: 12 hrly; age > 7 days: 8 hrly × 2–3 weeksPLUS
- Vancomycin 15 mg/kg/dose; age <7 days: 12 hrly and >7 days: 8 hrly × 2–3 weeks
Duration of treatment for gram–ve bacilli or Staph sp × at least 21 days
For 2 month and above
- First-line therapy
Note: If ceftriaxone not available, inj cefotaxime 200 mg/kg/day IV div q 8 hr/6 hr × 10–14 days
If clinically suspected staphylococcal infection, add inj. vancomycin; continue treatment for minimum 3 weeks
- Second-line therapy
- Inj. meropenem 120 mg/kg/day div q 8 hr × 10–14 daysPLUS
- Inj. vancomycin 60 mg/kg/day div q 6 hr × 10–14 days
- Subsequent drug therapy after isolation of organisms as per their antibiotic sensitivity.
- Meningococcal meningitis: Ceftriaxone × 7 days
- Haemophilus influenzae type b (Hib) meningitis: Ceftriaxone × 10 days
- Streptococcus pneumoniae type b meningitis: Ceftriaxone × 14 days.
- Other organisms: See Table 1.2.
Suspected Tuberculosis Infection
See under section “Drug Treatment of Childhood Tuberculosis”.
Ventriculoperitoneal Shunt Infection
- Initial: Vancomycin + ceftriaxone or cefotaxime + metronidazole
- Subsequently: As per organisms grown on culture:
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Brain Abscess
Infants and Children
- Initial: Vancomycin + cefotaxime or ceftriaxone + metronidazole IV
- Alternative: Meropenem IV + vancomycin
- Subsequently as per pus culture sensitivity:
- Duration of antibiotic therapy: 4–6 weeks.
Neonatal Meningitis with Brain Abscess
- Initial: Meropenem + aminoglycoside IV
- Subsequently: As per aspirated pus culture and sensitivity.
Encephalitis
(Herpes simplex virus)
See section “Viral infections”.
GASTROINTESTINAL INFECTIONS
Acute Gastroenteritis
Rotavirus and enterotoxigenic E. coli are responsible for nearly half, cholera for about 5–10% and Salmonella for about 3–7% cases of acute diarrhea in Indian children. Giardia lamblia is an uncommon cause. Several other bacteria; viruses and parasites also induce acute diarrhea.
Dysentery is caused largely by Shigella intestinal infection. Other causes for it are infection by Entamoeba histolytica, enteroinvasive and enterohemorrhagic E. coli, Salmonella, and Campylobacter jejuni.
Role of Antibiotic in Therapy
Antimicrobial agents have no role in treatment of diarrhea caused by Rotavirus and other viral intestinal infections. Antimicrobial therapy is chiefly indicated for cases of acute bloody diarrhea (caused mostly by Shigella infection), suspected cases of cholera and for infrequent cases of diarrhea due to protozoal (E. histolytica and Giardia) infection.18
Dysentery due to Shigella Infection
In view of widespread increasing resistance of Shigella organisms to different antibiotics, the preferred agents are now considered to be as follows:
- Ciprofloxacin 30 mg/kg/day div in BD PO × 3 days; watch clinical response closely for 48 hours
- In case of failure of response to ciprofloxacin, in moderately ill cases, switch to cefixime 8–10 mg/kg/day div in BD PO
- In a sick child, better initiate treatment with IVCeftriaxone instead of ciprofloxacin. Ceftrioxone 50–100 mg/kg/day div in BD IV × 3–5 days.
Cholera
- Antibiotics are recommended in children having moderate-to-severe dehydration
- Tetracycline 12.5 mg/kg/dose (max 500 mg/dose) four times a day PO × 3 days
- Or erythromycin 12.5 mg/kg/dose (max 250 mg) × four times a day × 3 days PO
- Or azithromycin 20 mg/kg (max 1 g) as a single dose PO
- Or doxycycline 2–4 mg/kg single dose PO
- Or ciprofloxacin 20 mg/kg (max 1g) as a single dose PO.
Salmonella Gastroenteritis (Nontypical Species)
Antibiotics are not indicated routinely in uncomplicated cases.
Indications for use: Infants (≤3 months of age) and other children who are at an increased risk of a disseminated disease, such as, children on immunosuppressive and corticosteroid therapy, patients suffering from acquired immunodeficiency syndrome (AIDS), malignancies, malaria, and malnutrition.
Helicobacter pylori Gastritis
At least two antibiotics + one potent proton pump inhibitor (Table 1.3).
Perirectal Abscess
Clindamycin + gentamicin or cefotaxime or ceftriaxone.
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Skeletal Infections
Arthritis (Septic)
- Infants <3 months (S. aureus, Enterobacteriaceae, Group B Strep)Oxacillin or nafcillin + cefotaxime or ceftriaxone IM/IV
- If MRSA: Vancomycin + cefotaxime or ceftriaxone IM/IV.
- Children (3 months–14 years) (S. aureus, Hib, S. pyogenes S. pneumoniae, gram-negative bacilli, and others)
- Vancomycin + cefotaxime or ceftriaxone or ceftizoxime.
Osteomyelitis (Acute)
- Neonate: See section “Neonatal Infections”
- Children <5 years: (S. aureus, Streptococcus, Hib) Cloxacillin or clindamycin + cefotaxime or ceftriaxone
- Children >5 years: (Staph, Strep) Cloxacillin or nafcillin or cefazolin IV
- Duration of treatment: 4–6 weeks or more
- If MRSA: Vancomycin or clindamycin instead of cloxacillin.
Osteomyelitis (Chronic)
Staphylococcal:
- Initial: Cloxacillin or nafcillin IV
- For MRSA: Vancomycin or clindamycin IV
- Later: Cloxacillin or first generation cephalosporin PO (cephalexin, cefadroxil, and cefazolin).
Osteomyelitis of the Foot-puncture Wound
Pseudomonas:
- Ceftazidime IV/IM or ticarcillin IV plus tobramycin or amikacin IV × 10 days
GENITOURINARY AND SEXUALLY TRANSMITTED INFECTIONS
Acute cystitis (uncomplicated lower UTI without urinary tract obstruction) (E. coli, Klebsiella, Proteus species, Enterobacter)
- Initial (before results of urine culture): Cotrimoxazole/ trimethoprim @ 8–10 mg/kg/day PO × 3–5 days
- After results of culture:
- If organisms on culture sensitive to it, continue cotrimoxazole × 7–10 days
- Or nitrofurantoin 5–7 mg/kg/div in TID/QID × 7–10 days
- Or amoxicillin 50 mg/kg/day div in TID/QID × 7–10 days
- Or cefixime 8–10 mg/kg/day div in BD × 7–10 days
- Or amoxicillin–clavulanate (30–50 mg of amoxicillin/kg/day) div in BD × 7–10 days.
Since it is difficult to distinguish between cystitis and pyelonephritis in infants and children below the age of 5 years, all cases of urinary tract infection (UTI) in this age group should be treated for 14 days.
Acute Pyelonephritis
(E. coli, Proteus, Klebsiella species, Staphylococcus saprophyticus, Enterococcus, and others)
It is advisable to choose the initial drug (on empirical basis before receipt of urine culture report) on the basis of known drug sensitivity of the likely source of infection:
Uropathogenic E. coli, the most common causative pathogen, in the community, or
That of locally prevalent flora in the institution or pediatric intensive care unit (PICU)
Initial (common choice): Ceftriaxone or cefotaxime IV or ampicillin + gentamicin IV
Later: As per antibiotic sensitivity of the organisms grown on culture
- Oral cefixime for gram-negative organisms almost as good as parenteral ceftriaxone (except against Pseudomonas)
- Do not use nitrofurantoin in a child with febrile UTI (inadequate renal tissue concentration).
Second line treatment for complicated UTI:
- Piperacillin tazobactam 90 mg/kg/dose q 6 h IV or IM or Meropenem 20–40 mg/kg/dose q 8 h × 10–14 days.
- Suspected urosepsis, child vomiting, infant <1 month: Parenteral drugs IV/IM × 10–14 days
- Older children: Initially parenteral, may give PO following improvement, total of 10–14 days.
Renal or Perinephric Abscess
Cloxacillin or nafcillin + gentamicin or ceftriaxone/ cefotaxime.
Epididymitis
(Young children—E. coli and S. aureus; older children—gonorrhea and Chlamydia)
Cefuroxime or cefotaxime or ceftriaxone × 7–10 days.
Add cloxacillin if suspected S. aureus infection. If C. trachomatis infection is suspected in sexually active adolescents or adults, add azithromycin or erythromycin or doxycycline
Vaginal Infections
- Bacterial vaginosis: Metronidazole × 7 days or single large dose
- Group A strep. infection: Penicillin V × 10 days PO
- Vulvovaginal candidiasis: See section “Fungal infections”.
Trichomoniasis
See section “Protozoal and other parasitic infections”.
Chancroid
(Haemophilus ducreyi)
Chlamydia trachomatis
- Erythromycin (or in >7 years old—doxycycline) × 7 days
- Alternative (in adults): Azithromycin 1 g PO, single dose
Gonorrhea
- Uncomplicated urogenital, anorectal, and pharyngeal infection
- Ceftriaxone 250 mg IM single dose + azithromycin 1 g PO once or
- Cefixime 400 mg PO once + azithromycin 1 g PO once or
- Ceftriaxone 250 mg IM single dose + doxycycline 100 mg BD PO × 7 days
- Alternative to ceftriaxone: Cefotaxime 500 mg IM; or ceftizoxime 500 mg IM
- Disseminated gonococcal infection:
- Ceftriaxone 1 g/day IM × 7–14 days + azithromycin 1g PO single dose
- Gonococcal conjunctivitis: Ceftriaxone 1 g IM single dose
- Gonococcal meningitis: Ceftriaxone 1–2 g IV q 12 hr × 10–14 days
- Gonococcal endocarditis: Ceftriaxone 1–2 g IV q 12 hr × 4 weeks or more.
Note: Concurrent therapy in these patients must be done for Chlamydia infection.
Syphilis
- Congenital: See section “Neonatal infections”
- Early: Primary, secondary, or latent <1 year
- Syphilis >1 year duration:
- Benzathine penicillin IM once weekly × 3 doses (50,000 U/kg, max 2.4 million units, divided over two injection sites)
- Alternative: For penicillin allergic patients—doxycycline PO × 4 weeks (4 mg/kg/day, max. 200 mg/day div in BID)
Neurosyphilis
Penicillin G IV (2.5 lac U/kg/day, max 24 million U/day div Q 6 hr) × 10–14 days.
MISCELLANEOUS SYSTEMIC INFECTIONS
Bacteremia or Sepsis
- Neonate: See section “Neonatal infections”
- Infants <3 months:
- Community-acquired pathogens: Pneumococcus, Hib, N. meningitides, Salmonella, E. coli, S. aureus, and other late-onset neonatal sepsis organisms, such as Group B Streptococcus and Listeria.
- Initial empiric treatment: Ceftriaxone or cefotaxime + ampicillin IV
- (If meningitis suspected, add vancomycin IV) to treatment as given above
- Suspected S. aureus infection: Cefotaxime + cloxacillin or nafcillin or clindamycin
- Herpes simplex infection: Acyclovir IV.
- Sepsis in older infants and children:
- Community-acquired infection: S. pneumoniae, N. meningitides, Salmonella, Hib in children age <5 years
- Initial: Ceftriaxone or cefotaxime
- Later: As per blood culture and sensitivity findings
- Nosocomial sepsis
Typhoid Fever
While planning treatment for typhoid fever watch for multidrug resistant S. typhi infection. Many S. typhi organisms are now resistant to chloramphenicol, cotrimoxazole, ampicillin, and amoxicillin. As such, these drugs are not recommended today for initial use on empirical basis. These may be considered later, if the organisms are found fully susceptible on culture.
If S. typhi organisms are found to be resistant to nalidixic acid on culture, nalidixic acid resistant S. typhi (NARST), it suggests that fluoroquinolone drugs (ciprofloxacin and ofloxacin) would not be clinically effective even if the organisms exhibit in vitro sensitivity to them.
Nalidixic acid and norfloxacin do not achieve adequate blood concentration after oral administration and should not be used. Ciprofloxacin and ofloxacin* are effective in some cases but their use has not been approved by the Drug Controller General of India for patient under 18 years of age except when the child is resistant to all other recommended drugs and is suffering from life-threatening infection.
- For cases of uncomplicated enteric fever (OPD cases):
- Cefixime: 15–20 mg/kg/day div q 12 h PO × 14 days (first-line drug)
- Azithromycin: 10–20 mg/kg/day (max 1 g/day) OD PO × 7–14 days. To continue till one week post-fever defervescence
- Amoxicillin: 75–100 mg/kg day div q 6 h PO × 14 days (if organisms sensitive)
- Trimethoprim-sulfamethoxazole (TMP-SMX): 8 mg, TMP, 40 mg SMX/kg/day div q 12 h PO × 14 days (if organisms sensitive)
- Chloramphenicol:* 50–75 mg/kg/day div q 6 h PO × 14 days (if organisms sensitive)
- For cases of severe enteric fever (requiring parenteral therapy):
- First line:Ceftriaxone: 75–100 mg/kg/day div q 24 h/12 h IV/IM × 14 daysor Cefotaxime: 100 mg/kg/day div q 6 h IV/IM × 14 days(On resolution of fever following IV use of ceftriaxone or cefotaxime, these may be replaced by oral cefixime 20 mg/kg/day—continue till one week after subsidence of fever)or Ciprofloxacin: 15–20 mg/kg/day div q 12 h IV × 10–14 days (max 800 mg/day)or Ofloxacin: 15–20 mg/kg/day div q 12 h IV × 10–14 days; continue for 1 week post-fever defervescence)
- If organisms sensitive; may use:
- Chloramphenicol: 50–75 mg/kg/day × 14 days, or
- Ampicillin: 100 mg/kg/day × 14 days or
- Trimethoprim-SMX: 8 TMP, 40 SMX mg/kg/day × 14 days.
- Second line:
- Some authorities recommend that in severe cases requiring hospitalization, a third generation cephalosporin (ceftriaxone or cefixime) may be used in combination with a quinolone (ciprofloxacin or ofloxacin) or with azithromycin.
- For non-responders, serious cases (may use):
- Aztreonam: 90–120 mg/kg/day div q 6–8 h IV/IM × 14 days
Adjunctive use of dexamethasone initially 3 mg/kg followed by 1 mg/kg every 6 hours for 48 hr and then gradual reduction of dose over next 3 days has been found useful in severe cases of typhoid fever, presenting with delirium, obtundation, stupor, coma or shock, alongwith other supportive treatment.
Shorter duration of therapy with some antibiotics has been found to be equally effective by some workers. It is generally recommended that antibiotic therapy should be continued for 5–7 days after the child becomes afebrile.27
Peritonitis
- Acute primary peritonitis (without a demonstrable intra-abdominal source) (usually monomicrobial) common: pneumococci, group A streptococci, staphylococci, gram–ve enteric bacteria.TreatmentInitial: Cefotaxime IVLater: As per culture sensitivity findingsFor resistant pneumococci: VancomycinDuration of treatment: 10–14 days
- Acute secondary peritonitis (due to entry of enteric bacteria into the peritoneal cavity through a necrotic defect in wall of the intestines/other viscus) (usually polymicrobial infection)TreatmentInitial choice of antibiotic:
- For lower GIT perforation cases.Ampicillin, gentamicin + clindamycin or metronidazole
- For peritoneal catheter-related peritonitisIntraperitoneal cefepime or cefazolin + ceftazidime
Later: As per antibiotic sensitivity of peritoneal fluid isolate.
Endocarditis
- Unknown organisms (no prosthetic valve); empirical therapy:
- Initial: Vancomycin + gentamicin (4–6 weeks)
- Later: As per antibiotic sensitivity of cultured organisms
- Strep. viridans and Streptococcus bovis:
- Penicillin G or ceftriaxone + gentamicin IV
- If penicillin allergy: Vancomycin + gentamicin IV
- Staphylococcus aureus and S. epidermidis:Cloxacillin or nafcillin + gentamicin
Pericarditis (Purulent)
- Empiric (S. aureus, Hib, Strep pneumoniae, Group A streptococci and gram-negative organisms)
- Initial: Vanco + cefepime
- Later: As per pericardial fluid cultured organism's antibiotic sensitivity.
- Staphylococcus aureus
- Cloxacillin or cefazolin IV; vancomycin (if methicillin-resistant) IV × 3–4 weeks
- Alternative: Imipenem.
Pericarditis (Tuberculous)
See section “Treatment of tuberculosis”.
Tetanus
- Penicillin G IV (200,000 U/kg/day div q 6 h) × 10–14 days or metronidazole IV (30 mg/kg/day div q 8 h) × 10–14 days
- Tetanus immunoglobulin (TIG) or tetanus antitoxin (TA): For details see under section on “Vaccines and immunoglobulins”.
Septic Shock Syndrome
Critically Ill Child with Severe Sepsis and Septic Shock
Guiding principles for initial presumptive therapy:
- Provide coverage for MRSA
- If suspected GIT source (e.g. burst appendicitis) or genitourinary infection—cover for enteric organisms
- Immunocompromised child—cover for Pseudomonas infection
- Modify later depending upon culture reports and patient's response.
Immunocompetent Children >28 Days of Age
- If suspected genitourinary source → Add aminoglycoside (genta or amika)
- If suspected GIT source → Add piperacillin-tazobactam or clindamycin or metronidazole.
Immunosuppressed >28 Days of Age or Risk of Pseudomonas Species Infection
- Ceftazidime or cefepime + vancomycin or teicoplanin
- If extended-spectrum β-lactamases (ESBL) resistant organisms present → add aminoglycoside or carbapenem. Carbapenem addition preferable, if any broad spectrum antibiotic received within 2 weeks, such as third generation cephalosporin, aminoglycoside, or fluoroquinolone.
Allergic to Penicillin or Recently Received Broad-Spectrum Antibiotic
- Vancomycin or teicoplanin + meropenem
- Alternative to meropenem: (i) aztreonam or (ii) ciprofloxacin + clindamycin.
Patient at Increased Risk of Fungal Infections
- Immunocompromised with persistent fever on broad-spectrum antibiotics or
- With an identified fungal source
Add the following antifungals to the antimicrobial regimen:
- Liposomal amphotericin B or
- Caspofungin or micafungin or anidulafungin.
Patients with Risk Factors for Rickettsial Infection (Travel to or Reside in an Endemic Region)
- Add doxycycline or tetracycline to the antibiotic regimen
Duration of Antibiotic Therapy for Sepsis
- If no complication: 7–10 days
- Longer course recommended: If slow clinical response; undrainable foci of infection; S. aureus bacteremia; some fungal and viral infections; or immunologic deficiency.
If MRSA infection suspected: Empirical therapy recommended with vancomycin; If minimum inhibitory concentration (MIC) value for MRSA isolates 12 mg/mL—use daptomycin. Linezolid should not be used for empirical therapy.