No commercial involvement of any kind has been solicited or accepted in the development of the content of this publication. Each tier offers increasingly broad spectrum activity, from the narrowest gram-negative agents to the broadest (and most toxic), colistin.
ANTIMICROBIAL DOSAGES FOR NEONATES —Lead author Jason Sauberan, assisted by the editors and John Van Den Anker Dosages (mg/kg/day) and Intervals of Administration
Use of Antimicrobials During Pregnancy or Breastfeeding
In general, a longer duration of therapy should be used (1) for tissues in which antibiotic concentrations may be relatively low (eg, undrained abscess, central nervous system [CNS] infection); Antimicrobial therapy according to clinical syndromes of 6 spp, species; STEC, Shiga toxin-producing E coli; STD, sexually transmitted infection;.
Antimicrobial therapy according to clinical syndromes NOTE: CA-MRSA (see Chapter 4) is widespread in most areas of the world, but may now be decreasing, rather than increasing.1 Recommendations regarding Antibiotic recommendations "for CA-MRSA" should be used for empiric therapy in regions with more than 5% to 10% of invasive staphylococcal infections caused by MRSA, in situations where CA-MRSA is suspected, and for documented CA-MRSA infections, while "standard recommendations" refer to treatment of MSSA.
Mupirocin OR retapamulin topical (BII) for lesions time; OR for more extensive lesions, oral therapy Standard: cephalexin 50–75 mg/kg/day PO div time. Penicillin G 200,000 U/kg/day IV div q6h (BII) initially, then penicillin V 100 mg/kg/day PO div qid OR amoxicillin 50 mg/kg/day PO div time for.
Antimicrobial therapy according to clinical syndromes NOTE: CA-MRSA (see Chapter 4) is prevalent in most areas of the world, although epidemiological data suggest that MRSA infections are fewer.
Antibiotic recommendations for empiric therapy should include CA-MRSA when suspected or documented, while treatment for MSSA with beta-lactam antibiotics (eg, cephalexin) is preferred over clindamycin. Empiric therapy: clindamycin (to cover CA-MRSA unless clindamycin resistance is locally .10%, then use vancomycin).
EYE INFECTIONS
Total treatment (IV plus PO) usually 4-6 weeks for MSSA (with normal ESR at end of treatment, x-ray to document healing), but can be as short as 3 weeks for mild infection. For MSSA (BI) and Kingella (BIII), step-down oral treatment with cephalexin 100 mg/kg/day PO various times.
EAR AND SINUS INFECTIONS
For adolescents: cefepime 150 mg/kg/day IV div q8h AND clindamycin 40 mg/kg/day IV div q8h (BIII). Antibiotics only for acute superinfections (according to the culture of drainage); for Pseudomonas: meropenem 60 mg/kg/day IV div q8h, OR pip/tazo 240 mg/kg/day IV div q4-6h for only 5-7 days after drainage stop (BIII).
Usual therapy: amoxicillin 90 mg/kg/day PO div bid, with or without clavulanate; amoxicillin failures in children not immunized with PCV13 are most likely to be caused by beta-lactamase-producing Haemophilus (or Moraxella). Same antibiotic therapy as for AOM as pathogens similar: amoxicillin 90 mg/kg/day PO div bod, OR for children at higher risk of Haemophilus, amox/.
Oral acyclovir is safe and effective for varicella; 75 mg/kg/day divided into 5 equal doses has been studied for HSV.115 The maximum daily dose of acyclovir should not exceed 3200 mg. A 5-day course of treatment is FDA-approved for azithromycin at 12 mg/kg/day for 5 days, and several oral cephalosporins are approved (cefdinir, cefpodoxime), with a rapid clinical response to treatment that can also be seen with conventional antibiotics. others; A 10-day course is preferred for the prevention of ARF, especially in areas where ARF is prevalent, as there are no data on the efficacy of 5-day therapy for the prevention of ARF.126,128.
LOWER RESPIRATORY TRACT INFECTIONS
Alternatives: IV imipenem or IV pip/tazo (BIII) Oral taper therapy with clindamycin or amox/clav. Corticosteroids are the mainstay of therapy for exacerbations, and itraconazole has a marked corticosteroid-sparing effect.
Cefepime 150–200 mg/kg/day div q8 h or meropenem 120 mg/kg/day div q6 h AND tobramycin 6–10 mg/kg/day IM, IV div q6–8 h to treat acute irritation (AII); alternatives: imipenem, ceftazidime, or ciprofloxacin 30 mg/kg/day PO, IV div tid. Chronic inflammation (Minimize long-term lung damage.) Inhaled tobramycin 300 mg twice daily, cycling 28 days on, 28 days off, is effective adjunctive therapy between exacerbations (AI).148,151.
Empiric oral outpatient therapy for less severe disease: high-dose amoxicillin 80-100 mg/kg/day PO div tid (NO bid) (BIII). Empiric oral outpatient therapy for less severe disease: high-dose amoxicillin 80–100 mg/kg/day PO div tid (NO bid); for Mycoplasma, ADD a macrolide as previously described (BIII).
If Chlamydia trachomatis is suspected, azithromycin 10 mg/kg on day 1, followed by 5 mg/kg/day every day 2–5 OR erythromycin 40 mg/kg/day PO div qid for 14 days (BII). Pneumonia: With pleural fluid/empyema (same pathogens as for community-associated bronchopneumonia) (Based on extent of fluid and symptoms, may benefit from chest tube drainage with fibrinolysis or video-assisted thoracoscopic surgery.
Antimicrobial therapy according to clinical syndromes – CMV (immunocompromise. See Chapters 5 and 9 for CMV infection in neonates and older children, respectively.). New data presented in 2018 in adults suggest that results with pip/tazo are inferior to carbapenems.194 For KPC-producing strains that are resistant to meropenem: alternatives include ceftazidime/avibactam (FDA-approved for adults, pediatric studies next), fluoroqui , or.
Severe disease: preferred regimen is TMP/SMX, 15-20 mg TMP component/kg/day IV div q8h for 3 weeks (AI). Prophylaxis: TMP/SMX as 5 mg TMP/kg/day PO, divided into 2 doses, q12h, daily or 3 times/week on consecutive days (AI); OR TMP/SMX 5 mg TMP/kg/day PO as a single dose, once daily, given 3 times/week on consecutive days (AI);
Empirical therapy: if not immunized, febrile, mildly to moderately toxic: after blood culture: ceftriaxone 50 mg/kg IM (BII). For a more acute, severe infection, add vancomycin 40-60 mg/kg/day IV div q8h to cover S aureus (AIII).
Fully responsive to penicillin Ceftriaxone 50 mg/kg IV, IM q24h for 4 weeks OR penicillin G 200,000 U/kg/day IV div q4-6h for 4 weeks (BII); OR penicillin G or ceftriaxone AND gentamicin 6 mg/kg/day IM, IV div q8h (AII) for 14 days for adults (4 weeks for children per AHA guidelines due to lack of data in children). For penicillin-nonsusceptible strains of pneumococcus, use high-dose penicillin G 300,000 U/kg/day IV div q4-6h or high-dose ceftriaxone 100 mg/kg IV q24h for 4 weeks.
If treatment fails, consider daptomycin (dose dependent on age; see Chapter 11) AND gentamicin 6 mg/kg/day every 8 hours. Antimicrobial therapy based on clinical syndromes – S aureus For MSSA: oxacillin/nafcillin 150–200 mg/kg/day IV.
GASTROINTESTINAL INFECTIONS (See Chapter 10 for parasitic infections.)
150 mg/kg/day div q8h; for 10-14 days (AIII) Ampicillin for beta-lactamase-negative strains - Pneumococcus, meningococcus,. 150 mg/kg/day div q8h for 3 weeks or longer (AIII) Alternative drugs depending on susceptibility; for Enterobacter, Serratia or Citrobacter, use cefepime or meropenem.
OR for susceptible strains: TMP/SMX 8 mg/kg/day TMP PO div bid for 14 days (AI). 2019 Nelson's Pediatric Antimicrobial Therapy — 105 Enteropathogenic Neomycin 100 mg/kg/day PO div q6–8 h for 5 days Most traditional “enteropathogenic” strains are not.
Antimicrobial therapy according to clinical syndromes Intra-abdominal infection (abscess, peritonitis secondary to bowel/appendix contents). Many other regimens may be effective, including ampicillin 150 mg/kg/day div q8h AND gentamicin 6-7.5 mg/kg/day IV, IM div q8h AND metronidazole 40 mg/kg/day IV div q8h; OR ceftriaxone 50 mg/kg q24h AND metronidazole 40 mg/kg/day IV div q8h.
250 mg IM as a single dose Alternative: erythromycin 1.5 g/day PO div daily for 7 days OR ciprofloxacin 1000 mg PO qd, div bid for 3 days Chlamydia trachomatis. Optional regimen: ceftriaxone 250 mg IM for 1 dose AND doxycycline 200 mg/day PO div bid; ME/.
Bacterial vaginosis56,304 Metronidazole 500 mg PO twice daily for 7 days OR metronidazole vaginal gel (0.75%) qd for 5 days OR clindamycin vaginal cream for 7 days. Alternative: tinidazole 1 g PO qd for 5 days, OR clindamycin 300 mg PO bid for 7 days Relapse common.
If CA-MRSA is suspected, ADD vancomycin 60 mg/kg/day IV div q8h ± rifampin 20 mg/kg/day IV div q12h, pending culture results. We have successfully treated MRSA intracranial infections with ceftaroline, but no prospective data exist: ceftaroline: 2–.6 months, 30 mg/kg/day IV div q8h (each dose given over 2 hours);
The first dose of dexamethasone is given before or at the same time as the first dose of antibiotics; likely little benefit if given $1 hour after antibiotics.316,317 – Empirical therapy318 Cefotaxime 200–300 mg/kg/day IV div q6h, or. Corticosteroids (may use same dexamethasone dose as for bacterial meningitis, 0.6 mg/kg/day IV div q6h) for 4 weeks until neurologically stable, then taper for 1-3 months to decrease neurological.
URINARY TRACT INFECTIONS
For moderate to severe disease (possible pyelonephritis), obtain cultures and start oral 2nd or 3rd generation cephalosporins (cefuroxime, cefaclor, cefprozil, cefixime, ceftibuten, cefdinir, cefpodoxime), oral ciprofloxacin, or IM ceftriaxone. Alternative: amoxicillin 30 mg/kg/day PO div tid OR amoxicillin/clavulanate PO if sensitive (BII);
MISCELLANEOUS SYSTEMIC INFECTIONS
Appendicitis (See Table 6H, Gastrointestinal infections, Intra-abdominal infection, Appendicitis.) Brucellosis341–344 Doxycycline 4.4 mg/kg/day PO (max. 200 mg/day) div. ADD gentamicin 6-7.5 mg/kg/day IV, IM div q8h for the first 1-2 weeks of therapy to further reduce the risk of relapse344 (BIII), especially for.
2019 Nelson's Pediatric Antimicrobial Therapy — 121 Cat-scratch disease (Bartonella . henselae)345-347 Supportive treatment for adenopathy (I&D of infected lymph node); azithromycin 12 mg/kg/day PO qd for 5 days shortens the duration of adenopathy (AIII). ADD vancomycin 40 mg/kg/day IV div q8h for suspected MRSA or coagulation-negative staph (eg, central catheter infection) (AIII).
Alternative recovery therapy: amox/clav (90 mg/kg/day amox div three times a day, not twice a day) for children. Antimicrobial therapy according to clinical syndromesQ fever (Coxiella burnetii)377,378 Acute stage: doxycycline 4.4 mg/kg/day (max. 200 mg/.
Preferred therapy for specific bacterial and mycobacterial pathogens 7 commonly used antibiotics (one agent per class listed). scale 0 to ++ defined in footnote) Cefazolin/. Preferred therapy for specific bacterial and mycobacterial pathogens 7 commonly used antibiotics (one agent per class listed). scale 0 to ++ defined in footnote) Ceftriaxone/.
For serious infections: doxycycline AND gentamicin AND rifampicin; or TMP/SMX AND gentamicin AND rifampicin (AIII). BabyBIG is available nationally from the California Department of Public Health at www.infantbotulism.org; . accessed 3 October 2018) Clostridium difficile 56–58 Associated with antibiotics.
Increasing resistance to third-generation cephalosporins (ESBLs) and carbapenems (KPC), as well as to colistin. Moraxella catarrhalis106 Otitis, sinusitis, bronchitis Amox/clav (AI) TMP/SMX; a 2nd or 3rd generation cephalosporin.
Pneumonia Clarithromycin (AII) or azithromycin. AII) AND ethambutol ± rifampicin Depending on the susceptibility and severity of the disease, ADD amikacin ± ciprofloxacin. Preferred therapy for specific bacterial and mycobacterial pathogens Neisseria gonorrhoeae45 Gonorrhea; arthritis Ceftriaxone AND azithromycin or Neisseria gonorrhoeae45 Gonorrhea; arthritis Ceftriaxone AND azithromycin or.
Use the most narrow-spectrum agent active against pathogen: PO ampicillin (not amoxicillin for enteritis); TMP/SMX. Preferred therapy for specific bacterial and mycobacterial pathogens Spirillum minus168,169 Rat-bite fever (sodoku) Penicillin G IV (AII); for endocarditis, Spirillum minus168,169 Rat bite fever (sodoku) Penicillin G IV (AII); for endocarditis,.
Treponema pallidum45,191 Syphilis (See Chapters 5 and 6) Penicillin G (AII) Penicillin desensitization preferred over alternative therapies. Vibrio vulnificus195,196 Sepsis, necrotizing fasciitis Doxycycline AND ceftazidime (AII) Ciprofloxacin AND cefotaxime or ceftriaxone Yersinia enterocolitica197,198 Diarrhea, mesenteric.
Posaconazole PO, voriconazole PO, and micafungin IV are effective in preventing yeast and mold infections in adults, but have not been well studied in children for this indication.12. Once stable, may transition from IV voriconazole to oral voriconazole at 18 mg/kg/day twice daily for children 2–12 years of age and at least 400 mg/day twice daily for children 12 years of age (AII) .
For children receiving ECMO, fluconazole is dosed at 35 mg/kg on day 1, followed by 12 mg/kg/day (BII).57 For non-neutropenic patients: So is an echinocandin. For children receiving ECMO, fluconazole is dosed as a dose of 35 mg/kg followed by 12 mg/kg/.
Pyelonephritis: fluconazole 12 mg/kg qd IV or PO for 2 weeks (AIII) after a loading dose of 25 mg/kg/day. For meningitis or severe pulmonary disease: induction therapy with AmB-D 1 mg/kg/day IV q24h OR ABLC/.
Abbreviations: AASLD, American Association for the Study of Liver Diseases; AIDS, acquired immunodeficiency syndrome; ART, antiretroviral therapy; ARV, antiretroviral; pray, twice a day; BSA, body surface area; CDC, Centers for Disease Control and Prevention; CLD, chronic lung disease; CMV, cytomegalovirus; CrCl, creatinine clearance; DAA, direct-acting antiviral agent; div, divide; EBV, Epstein-Barr virus; FDA, US Food and Drug Administration; G-CSF, granulocyte colony-stimulating factor;. HAART, highly active antiretroviral therapy; HBeAg, hepatitis B e antigen; HBV, hepatitis B virus; HCV, hepatitis C virus; HHS, US Department of Health and Human Services; HIV, human immunodeficiency virus; HSV, herpes simplex virus; IFN, interferon; IG, immune globulin; IM, intramuscular; IV, intravenous; PO, oral; postmenstrual age, weeks of pregnancy since last menstruation PLUS weeks of chronological age since birth; PTLD, posttransplant lymphoproliferative disorder; PREP, preexposure prophylaxis; qd, once daily; qid, 4 times a day; RSV, respiratory syncytial virus;.
Brincidofovir, the orally available lipophilic derivative of cidofovir also known as CMX001, is under investigation for the treatment of adenovirus in immunocompromised hosts. Pleconaril PO is currently under consideration for submission to the FDA for approval for the treatment of neonatal enteroviral sepsis syndrome.22 As of November 2018, it is not available for compassionate use.
Treatment is not recommended for children with immunotolerant chronic HBV infection (ie, normal serum transaminase levels despite detectable HBV DNA) (BII). It is expected that additional safe and effective DAA regimens will be available in the near future for children 3-11 yrs.
Preferred therapy in the first 2 weeks after birth is zidovudine and lamivudine PLUS either nevirapine or raltegravir. Preferred regimens include abacavir and lamivudine or TAF and either lamivudine or emtricitabine PLUS or atazanavir/ritonavir OR dolutegravir ($30 kg).
