Paediatric Empirical Antimicrobial Guidance for Infections ... · Consider re-LP after 2 weeks depending on the initial LP result. NB: MRF advice is to empirically treat with cefotaxime

Author: NHS Fife Antimicrobial Management Team Updated April 2017 Authorised by: NHS Fife AMT / MSDTC Review Date: February 2018

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Paediatric Empirical Antimicrobial Guidance for Infections in Hospital

This guidance is for empirical treatment. Alternative antibiotics may be required if specific pathogens are identified or there is failure to respond.

Contact microbiology for advice.

Samples should be taken for culture sensitivity testing whenever possible and preferably before the administration of antibiotics. If appropriate, modify initial therapy once sensitivity results are available.

Viral infections and self-limiting illnesses should not be treated with antibiotics.

The route of administration depends on the severity of the infection. Review the need for IV treatment after 48 hours and then at least every 24

hours, changing to oral therapy as soon as possible. See appendix 1

The duration of therapy depends on the nature of the infection and the response to treatment. Use the shortest, effective duration of treatment.

All antimicrobial prescriptions should have a review date or duration of treatment stated on the prescription chart The indication for prescribing antibiotics MUST be clearly documented in the patients’ medical notes

Consider whether monitoring of drug levels is required e.g. Gentamicin and Vancomycin.

The dose of an antimicrobial varies according to age, weight, hepatic/renal function and severity of infection. Refer to current BNF for

children for dosing guidance and also for any potential drug interactions. It is important to clarify the history of a reported penicillin allergy. Those with a type 1 allergy to penicillin maybe prescribed

cephalosporins or carbapenems for severe infections under close observation. Seek microbiology advice if also history of severe allergy to cephalosporins and/or carbapenems. See appendix 2.


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Community Acquired Sepsis

Recognition of Sepsis

A child with suspected or proven infection AND at least 2 of the following:

● Core temperature <36°C or >38°C (observed or reported in previous 4 hours)

● Inappropriate tachycardia (Refer to National PEWS)

● Altered mental state (including: sleepiness / irritability / lethargy / floppiness)

● Reduced peripheral perfusion / prolonged central capillary refill / cool or mottled peripheries

Reduce Threshold for Sepsis

Some children are at higher risk of sepsis. You may consider treatment with fewer signs than above. These include, but are not

restricted to:

● Infants under 3 months

● Immunosuppressed / immunocompromised / chemotherapy / long term steroids

● Recent surgery

● Indwelling devices / lines

● Complex neurodisability or other long term conditions (may not present with high PEWS but observations may vary from their baseline)

● High index of clinical suspicion


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Community Acquired Sepsis

Infection Recommended Therapy Expected Duration Notes Community-acquired sepsis in children >28 days old

Cefotaxime IV

Seek Microbiologist advice Obtain travel history. Consider adding gentamicin if Pseudomonas or other resistant gram negative infection suspected. Consider adding clindamycin if Group A Streptococcus sepsis is suspected. Review when culture results are available. Seek microbiology advice if needed.

Neutropenic sepsis (Not previously known to have underlying condition e.g.’haematological/oncological’ malignancy)

Piperacillin-tazobactam IV

If true penicillin allergy:

Seek Microbiology advice

Seek Microbiologist advice Take blood cultures before giving antibiotics. Consider adding gentamicin if Pseudomonas or other resistant gram negative infection suspected. Obtain all other microbiology specimens as soon as possible. Review when culture results are available. Seek microbiology advice if needed.

Suspected/confirmed methicillin sensitive Staphylococcus aureus (MSSA) bacteraemia

Flucloxacillin IV If true penicillin allergy:

Vancomycin IV

Minimum duration: 14 days

Suspected/confirmed methicillin resistant Staphylococcus aureus (MRSA) bacteraemia

Vancomycin IV Minimum duration: 14 days

For information on monitoring serum levels refer to monographs.


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Central Nervous System Infections

Please refer to meningitis research foundation algorithm http://www.meningitis.org/assets/x/53067

Infection Recommended Therapy Expected Duration Notes Meningitis (neonate and child ≤3 mths old)

Empiric Treatment: Early-onset (up to 28 days)

Benzylpenicillin IV Plus

Gentamicin IV


Seek Microbiology advice Late onset (after 28 days)

Cefotaxime IV

Group B Streptococcus:

Benzylpenicillin IV Plus

Gentamicin IV



Gram-negative bacilli

Cefotaxime IV

Listeria monocytogenes:

Amoxicillin IV Plus

Gentamicin IV



If organism unknown, treat for 14 days. Treat Group B streptococcal infection for at least 14 days. May require 21 days or longer if ventriculitis, cerebritis or suppurative complications occur.

Treat Gram-negative meningitis for at least 21 days with cefotaxime.

Treat Listeria meningitis for 21 days. Consider stopping gentamicin after 7 days.

Obtain travel history and consider adding Vancomycin IV if recently overseas or prolonged or multiple antibiotic exposure within last 3 months Change treatment once organism identified. Once a clinical diagnosis is made, report case to a Consultant in Public Health Medicine.

Consider repeating LP after 48 hours of treatment if lack of response. Consider re-LP after 2 weeks depending on the initial LP result. NB: MRF advice is to empirically treat with cefotaxime plus amoxicillin. Locally we have not seen isolates of Streptococci with reduced susceptibility to penicillin, so we will continue to use our current regimen. Similarly MRF advise cefotaxime for confirmed Group B Streptococcus. Locally we have not encountered isolates against which this would be any more effective than benzylpenicillin. We will continue to monitor local resistance patterns.

http://www.meningitis.org/assets/x/53067


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Infection Recommended Therapy Expected Duration Notes Meningitis (>3 months to 16 years) Viral encephalitis

Cefotaxime IV

Obtain travel history and consider adding Vancomycin IV if recently overseas or prolonged or multiple

antibiotic exposure within last 3 months.

Aciclovir IV (as per local protocol)

If organism unknown, treat for at least 10 days. Treat pneumococcal meningitis for a minimum of 14 days. Up to 21 days may be required if cerebritis or suppurative complications occur. Treat meningococcal meningitis for a minimum of 7 days. Treat haemophilus meningitis for a minimum of 10 days. Minimum 21 days

Obtain travel history and consider adding Vancomycin IV if recently overseas or prolonged or multiple antibiotic exposure within last 3 months. Contact Public Health Medicine to deal with prophylaxis for contacts. Consider repeating LP after 10 days of treatment. Patients should be adequately hydrated during high dose aciclovir therapy. Ensure urine output is at least 1 ml/kg/hr. Re-check CSF prior to completion of therapy. If viral PCR remains positive, a further seven days of therapy is advised (BIA guidelines 2012).


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Gastrointestinal System

In the presence of bloody diarrhoea, consider the possibility of infection with E. Coli 0157. Unless the patient is septic, antibiotics are not appropriate for

bloody diarrhoea because of the risk of precipitating Haemolytic Uraemic Syndrome. Seek microbiologist advice.

Infection Recommended Therapy Expected Duration Notes Acute viral gastroenteritis Antimicrobial therapy seldom indicated

unless systemic invasion is suspected. Consult Microbiology before starting antibiotics.

Acute Bacterial gastroenteritis

Salmonella: Cefotaxime IV

Shigella / Campylobacter: Ciprofloxacin oral

10-14 days for cefotaxime IV 5 days for oral ciprofloxacin

Obtain travel history for all cases. Contact microbiology if required

Initial management is supportive until a pathogen has been isolated. Give empirical antibiotic treatment if:

Confirmed or suspected sepsis

Age <6 months

Immunocompromised

Malnourished

Haemoglobinopathy and suspected Salmonella gastroenteritis

Those with bacteraemia will require prolonged IV therapy. Discuss with microbiology.

Enteric fever (Typhoid and Paratyphoid)

Cefotaxime IV Treat bacteraemia and severe infection treat for 10-14 days.

Beware of complications e.g. osteomyelitis, meningitis. If these present, treatment should be given for longer. Seek Microbiologist advice

Mild/Moderate Clostridium difficile infection

If treatment required: Metronidazole oral

10 to 14 days. Stop at day 10 if symptoms resolved.

Stop all concurrent antibiotics if possible. Seek microbiology advice if antibiotics cannot be stopped.

Severe Clostridium difficile infection (immunocompromised, or abdominal tenderness, or fever, or raised WBC or declining renal function)

Vancomycin oral 10 to 14 days. Stop at day 10 if symptoms resolved.

If patient unable to tolerate oral or NG vancomycin, give metronidazole intravenously. Do not use vancomycin IV.

Pseudomembranous colitis

Vancomycin oral (high dose) Plus

Metronidazole IV

Seek microbiology advice Seek urgent GI or surgical review


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Infection Recommended Therapy Expected Duration Notes Community acquired peritonitis Hospital acquired peritonitis

Cefotaxime IV Plus

Metronidazole IV



Minimum 7 days Concomitant surgical management is important. Patients with complicated peritonitis, previously treated with broad-spectrum antibiotics are at risk of infection with multi-resistant organisms. In addition empirical antifungal therapy (e.g. fluconazole) may be considered for patients with complicated postoperative intra-abdominal infections.

Ascending cholangitis and acute cholecystitis

Cefotaxime IV Plus

Metronidazole IV



7 – 10 days The role of antibiotics in uncomplicated acute cholecystitis remains unclear.

If not improving, consider adding gentamicin and seek microbiology advice.

Spontaneous bacterial peritonitis in pre-existing liver disease

Cefotaxime IV Plus

Metronidazole IV



Seek urgent surgical and GI review.

In patients with liver disease and ascites consider peritoneal tap and send aspirate for urgent microscopy and culture. Prophylaxis may be required after treatment of infection. Seek GI advice.

Peritonitis associated with dialysis Seek specialist advice.


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Respiratory System

General terms such as “lower respiratory tract infection” (LRTI) is not a diagnosis and can cover many infections – a more specific diagnosis must be sought and documented in the patient’s notes before appropriate treatment can be selected.

Respiratory Tract Infections

Infection Recommended Therapy Expected Duration Notes Mild Community-acquired pneumonia (CAP)

or

pneumonia within 48 hours of admission

Amoxicillin oral*


Clarithromycin oral

*Note: consider adding clarithromycin if mycoplasma pneumonia suspected

7 days in an uncomplicated pneumonia

Oral therapy is safe and effective in mild CAP. Intravenous amoxicillin or clarithromycin therapy is only indicated in those who cannot tolerate oral medication. For advice regarding antivirals in influenza, refer to HPS guidance:

http://www.documents.hps.scot.nhs.uk/respiratory/seasonal-influenza/antiviral-guidance-season-15-16-v2.pdf

Severe CAP or presents also with influenza:

Co-amoxiclav IV

Community aspiration pneumonia

Co-amoxiclav IV


Cefotaxime IV Plus

Metronidazole IV

Hospital-acquired pneumonia (>48 hours after admission)

Cefotaxime IV

Review risk of MRSA infection and available microbiology/virology results and seek advice.

Hospital aspiration pneumonia (>48 hours after admission)

Cefotaxime IV Plus

Metronidazole IV

Review risk of MRSA infection and available microbiology/virology results and seek advice.





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Infection Recommended Therapy Expected Duration Notes Bronchiectasis, acute exacerbation

Co-amoxiclav oral or IV



10 to 14 days

Review most recent culture and sensitivity results as this may guide treatment choice. If in doubt seek specialist respiratory advice

Cystic Fibrosis, acute infective exacerbation

Refer to Scottish Paediatric CF MCN prescribing guidelines

Respiratory Syncytial Virus (RSV) infection

Antibiotics not routinely recommended

Whooping cough

Clarithromycin oral or IV

7 days

If clinically suspected take NPA in children under 2 years old or a throat swab in older children (both in viral transport medium for PCR). This is a reportable disease and during working hours contact Public Health Medicine who will review the need for prophylaxis in contacts.

Varicella pneumonitis Aciclovir IV (high dose)

Minimum: 7 days Patients should be adequately hydrated during high dose aciclovir therapy. Ensure urine output is at least 1 ml/kg/hr.

Pneumocystis jiroveci pneumonia (PCP)

Co-trimoxazole IV (high dose)

Seek specialist advice

Minimum: 14 days. If immunocompromised, treat for 21 days.


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Musculoskeletal system

Skin and soft tissue infections In skin and soft tissue infections surgical review is often useful. Tetanus prophylaxis should not be forgotten.

Infection Recommended Therapy Expected Duration Notes Cellulitis and Erysipelas (for periorbital/preseptal cellulitis, see below)

Flucloxacillin IV or oral


Clindamycin IV

For uncomplicated cellulitis 7 days treatment is usually sufficient

Periorbital / Preseptal cellulitis Discussion with ophthalmology advised

Co-amoxiclav IV


Ciprofloxacin IV Plus

Clindamycin IV

10-14 days. Multi-disciplinary management including paediatric, ENT and Ophthalmology for review for any moderate, moderate/severe infections or if eye signs present (restricted eye movement, pain, proptosis, reduced vision).

Necrotising fasciitis Meropenem IV (Maximum dose) Plus

Clindamycin IV (Maximum dose)

Seek surgical review. Urgent surgical debridement is crucial.

Theatre specimens should be sent for microscopy and culture to help determine aetiology. Contact microbiology labs to arrange urgent examination.

Gas gangrene Benzylpenicillin IV Plus

Clindamycin IV


Vancomycin IV Plus

Clindamycin IV

The primary treatment for this condition is urgent surgical debridement.

Antibiotics have only a secondary role in therapy.

Gangrene develops in anaerobic areas with limited blood flow. Therefore, antibiotics do not penetrate and only protect contiguous areas.


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Infection Recommended Therapy Expected Duration Notes Serious post-operative wound infection: Clean procedure

Flucloxacillin IV


Clindamycin IV

If MRSA risk:

Vancomycin IV

7 days

Serious post-operative wound infection: Contaminated procedure

Co-amoxiclav IV

If MRSA risk:

+ Vancomycin IV


Vancomycin IV + Ciprofloxacin IV + Metronidazole IV

Send a wound swab for culture prior to initiating treatment. Further therapy should be guided by laboratory results.

Human/Cat/Dog bite Co-amoxiclav IV or Oral


Co-trimoxazole Oral + Metronidazole Oral

If bite was sustained abroad or if any other animal involved seek

microbiologist advice

7 days Obtain travel history Assess risk of tetanus; HIV; hepatitis B&C; in human bites and rabies (animal bites) Wound care and thorough irrigation is important. Consider tetanus prophylaxis. Give antibiotic prophylaxis in all human, cat, dog and puncture bites, especially when hand, foot, face, joint, tendon, ligament involved; or when patient immunocompromised, diabetic, asplenic, cirrhotic, presence of prosthetic valve or prosthetic joint

If accompanied by marked cellulitis consider parenteral antibiotic therapy and seek plastic surgery advice.


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Acute bone and joint infections Take blood cultures and send joint aspirates for culture before starting empirical antibiotic therapy.

Infection Recommended Therapy Expected Duration Notes Septic arthritis or Acute osteomyelitis

Empirical therapy:

Age: 0-3 months old:

Cefotaxime IV

If true penicillin allergy: Contact Microbiology

Age: >3 months:

Flucloxacillin IV Plus

Clindamycin IV


Clindamycin IV

Age: 0-3 months:

Initial intravenous therapy for 14 days, then duration of oral therapy will depend

on sensitivities. If cultures negative then use 4 weeks

oral co-amoxiclav

Age: >3 months

Initial intravenous therapy for 72 hours, then duration of oral therapy will depend

on sensitivities. If cultures negative then use 4 weeks

oral co-amoxiclav

In all cases seek specialist orthopaedic advice at the outset.

Do not start antibiotic therapy until appropriate samples have been obtained for

culture. In children >3 months to 5 years of age consider Kingella kingae. If unresponsive to initial therapy consider changing to ceftriaxone.

Chronic osteomyelitis Seek specialist orthopaedic advice. Appropriate specimens should be taken for culture prior to starting therapy


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Cardiovascular System

Bacterial Endocarditis Consult a Cardiologist immediately and liaise with the on-call Microbiologist. Ensure 3 sets of blood cultures are obtained PRIOR to initiation of antibiotic therapy and that adequate volumes are obtained.

If the disease is slowly progressing and the patient is stable, consider delaying antimicrobial therapy pending blood culture results.

For children with structural heart defects who are at risk of endocarditis who present with fever should have 2 sets of blood cultures prior to antimicrobial therapy irrespective of focus of infection.

Intravascular catheter-related sepsis It is important to obtain blood cultures through both the vascular catheter and peripheral venepuncture.

Infection Recommended Therapy Expected Duration Notes Intravascular catheter-related sepsis

Teicoplanin IV and

Gentamicin IV

10 days from line removal Teicoplanin is preferred to vancomycin because these patients frequently have single lumen vascular catheters and are often on TPN.

Discuss with the child’s specialty service

Central venous catheters, non-tunnelled (including arterial cannulae)

Vancomycin IV

10 days from line removal Discuss with Microbiology


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Genitourinary Tract Infections Delay in starting treatment is associated with increased risk of scarring. All children under 3 years of age who have not achieved day time continence, who have signs of an upper urinary tract infection require prophylaxis after treatment, and referral to the UTI clinic for further imaging.

Always review your choice of antibiotic as soon as cultures and sensitivities are available.

Infection Recommended Therapy Expected Duration Notes UTI in children < 3 months old

Seek senior paediatric advice

1st line

Co-amoxiclav IV

2nd

line (see notes) Amoxicillin IV

plus Gentamicin IV


Cefotaxime IV or

Ciprofloxacin IV

Suggest 3-5 days IV therapy initially, followed by 5 days oral therapy when

tolerated.

Suprapubic or clean-catch urine is required for diagnosis.

Treatment is followed with prophylaxis. All children aged < 6 months with systemic illness should be treated with intravenous therapy initially. Co-amoxiclav IV is appropriate initial therapy in moderately unwell infants. If more severely unwell, gentamicin plus amoxicillin may be appropriate (the combination of gentamicin and co-amoxiclav duplicates Gram negative cover and is not required)

Uncomplicated lower UTI (cystitis) in children >3 months old

Trimethoprim Oral Or

Nitrofurantoin Oral

Minimum 3 days

Send urine specimen for culture prior to initiating treatment if possible. If there is no clinical improvement by 48 hours perform a repeat urine culture, and consider other urgent investigations.

Stop prophylactic antibiotics during treatment and review sensitivities before re-commencing.


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Infection Recommended Therapy Expected Duration Notes Complicated upper UTI with systemic symptoms (including pyelonephritis) in children > 3 months old

1st line

Co-amoxiclav IV

2nd

line (see notes) Amoxicillin IV

plus Gentamicin IV


Ceftriaxone IV or

Ciprofloxacin IV

7 days

Consider longer if remains symptomatic.

Send urine specimen for culture prior to initiating treatment if possible. If there is no clinical improvement by 48 hours perform a repeat urine culture, and consider other urgent investigations.

Co-amoxiclav IV is appropriate initial therapy in moderately unwell infants. If more severely unwell, gentamicin plus amoxicillin may be appropriate (the combination of gentamicin and co-amoxiclav duplicates Gram negative cover and is not required) Consider multi-drug resistant organisms in those with relevant travel history or previous resistant culture results.

UTI post urological surgery Seek specialist advice from microbiology Urine must be sent for culture.

UTI Prophylaxis in the following groups 1. Less than 3 years old, after first

episode of UTI. 2. Recurrent UTI

Trimethoprim nocte Oral (If trimethoprim resistant, discuss with Microbiologist)

Review every 3-6 months Breakthrough infections are due to non-compliance or true antimicrobial resistance. If breakthrough infection occurs, review sensitivity of isolates before restarting antibiotic prophylaxis.

Vulvovaginitis Amoxicillin Oral


Erythromycin or Clarithromycin Oral Mebendazole Oral

5-7 days Use mebendazole for children aged over 6 months in combination with hygiene measures.

• Second dose may be required after 2 weeks.


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Eye infections

Infection Recommended Therapy Expected Duration Notes Conjunctivitis Most cases are viral and do not require antibiotic treatment. If no better after 3 to 5 days of eye toilet, consider antibiotic therapy.

Chloramphenicol 0.5 % drops. Apply 1 drop topically to each affected

eye 4 times daily.

5 days.

If no resolution after this time seek ophthalmology advice.

Use separate bottles for each eye.

Chloramphenicol ointment can also be used.

Consult Ophthalmologist if infection is severe, or if worsening signs. Neonatal conjunctivitis – see appendix 11A of Fife formulary: http://www.fifeadtc.scot.nhs.uk/formulary/11-eye/appendix-11a-neonatal-conjunctivitis.ASPX

For all other eye infections seek ophthalmology advice

Ear Nose and Throat Infections

See NHS Fife Primary Care Antibiotic Guidance

Common Viral Infections

Infection Recommended Therapy Expected Duration Notes Chickenpox Not usually required

If required, Aciclovir (oral if well, IV if

immunocompromised)

Treat for 10 days in total (intravenously for initial 7 days).

Treatment should be given to all immunocompromised patients and

continued until 48 hours after all lesions have crusted over, even if this means

treating for more than 10 days.

Antiviral therapy may be considered in adolescents in whom disease may be more severe than in younger children. Treatment should start within 24 hours of onset of rash.

In patients with symptoms / signs of pneumonitis, give IV therapy initially and watch for significant respiratory compromise

If admitted, child should be nursed in an isolation room. Beware: chickenpox is a highly contagious disease.

Shingles Consider oral Aciclovir

(if severe, or an immunocompromised patient: Aciclovir IV)

Minimum 7 days Aciclovir may reduce severity, pain and duration of viral shedding if treatment started within 72 hours of onset of rash.

Gingivostomatitis

In severe cases, Aciclovir orally

If immunocompromised, seek specialist advice.

http://www.fifeadtc.scot.nhs.uk/formulary/11-eye/appendix-11a-neonatal-conjunctivitis.ASPX

http://www.fifeadtc.scot.nhs.uk/formulary/11-eye/appendix-11a-neonatal-conjunctivitis.ASPX


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Prophylaxis Antibiotic prophylaxis for selected medical conditions

Condition/Infection Recommended Therapy Expected Duration Notes Meningococcal meningitis (contacts)

Ciprofloxacin oral For close contacts who are/may be pregnant Ceftriaxone 250 mg intramuscularly stat or Oral Ciprofloxacin can be used Prophylaxis is also recommended for the index case to eradicate nasopharyngeal carriage if they were not treated with ceftriaxone

Always discuss with on-call Consultant in Public Health Medicine (CPHM) without delay when clinical diagnosis has been made. Healthcare workers in close contact with the patient during for example mouth-to-mouth resuscitation and likely to have been exposed to respiratory secretions should be offered prophylaxis.

Haemophilus meningitis (contacts)

Rifampicin oral

Always discuss with on-call Consultant in Public Health Medicine (CPHM) without delay when clinical diagnosis has been made.

Splenectomy, hyposplenic, asplenic individuals

See NHS Fife splenectomy guidance


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Antibiotic Prophylaxis for Paediatric Surgery

Procedure Recommendation Penicillin allergy and / or MRSA infection / colonisation

Gastrostomy (associated with other procedures or alone)

Teicoplanin 10mg/kg IV (max 400mg) single dose

N/A

Biliary Surgery, (complex biliary atresia and choledocal cysts) Appendicectomy Colorectal and Small Bowel surgery

Amoxicillin 30 mg/kg IV (max 500mg) single dose plus Gentamicin 2.5 mg/kg IV (use IBW for dosing) single dose plus Metronidazole 7.5 mg/kg IV (max 500mg) single dose Not recommended in uncomplicated laparoscopic cholecystectomy

Teicoplanin 10 mg/kg IV (max 400 mg) single dose plus Gentamicin 2.5 mg/kg IV (use IBW for dosing) single dose plus Metronidazole 7.5 mg/kg IV (max 500mg) single dose

All Urinary Tract surgery where infection is suspected or confirmed.

1

st line

Gentamicin 2.5 mg/kg IV (use IBW for dosing) single dose 2

nd line

Coamoxiclav 30 mg/kg IV (max 1.2g) single dose Thereafter Trimethoprim 2 mg/kg oral (max 100mg) once daily until stent and catheter removed

If MRSA infection / colonisation, add Teicoplanin 10 mg/kg IV (max 400 mg) single dose


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Ear Nose and Throat Surgery Procedure Recommendation Penicillin allergy and / or MRSA infection / colonisation

Ear surgery (clean / clean contaminated) Tonsillectomy Adenoidectomy Routine nose, sinus and endoscopic sinus surgery Head and neck surgery (clean, benign)

Nil required

Grommet insertion

3 drops of Ciprofloxacin 0.3% eye drops into grommeted ear/s single dose

Thyroglossal Cyst surgery

Co-amoxiclav 30 mg/kg IV (max 1.2g) single dose

Teicoplanin 10 mg/kg IV (max 400 mg) single dose plus Gentamicin 2.5 mg/kg IV (use IBW for dosing) single dose plus Metronidazole 7.5 mg/kg IV (max 500mg) single dose

Documents

Paediatric Empirical Antimicrobial Guidance for Infections ... · Consider re-LP after 2 weeks depending on the initial LP result. NB: MRF advice is to empirically treat with cefotaxime