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Antibiotics 101
Etiology & Treatment of Bacterial Infections in Children
Antibiotics 101
PreambleKeys to Prudent Antibiotic UseSpecific Recommendations
Keys to Prudent Antibiotic Use
Recognize the probable site of infectionKnow the usual pathogensKnow local pathogen sensitivitiesUnderstand drug kinetics Anticipate drug adverse effectsLimit your personal formulary
Specific InfectionsPharyngitisOtitis Media & SinusitisPneumoniaSepticemiaMeningitisCellulitis Bone & Joint InfectionsUrinary Tract InfectionsNeonatal Infections
Penicillin V 50 mg/kg/day; Q 6-8 hours
Benzathine Penicillin25,000 U/kg
Cephalexin50 mg/kg/day; Q 6-8 hours
Clindamycin30 mg/kg/day; Q 6 hours
Therapy of GAS Pharyngitis
Etiology of Acute Otitis Media
Streptococcus pneumoniae Nontypeable Haemophilus influenzae Moraxella catarrhalis
Spontaneous Bacteriologic Resolution of Acute Otitis Media
Pathogen % Resolved Day 5
MCAT 75%Haemophilus 50%Pneumococcus 16%
Categories of S. pneumoniae
Susceptible to penicillin ........... ≤ 0.06 ug/mlIntermediate to penicillin ........... 0.1-1.0 ug/mlResistant to penicillin ............ ≥ 2.0 ug/ml
Prevalence of “Beta-Lactam Challenged” Pneumococci
National average 51%
< 6 years of age 60%
DCC attendance 65%
Recent Antibiotic Rx 65%
Some US populations 80%
Oral Antibiotics vs. Penicillin-intermediate S. pneumoniae
02468
1012141618
Amoxicilli
n
TMP/SMZ
Erythro
Cefaclo
r
Cefuro
xime
Cefixim
e
Cefpro
zil
mcg
MIC, 90%MEF levels
Bacteriologic Failure Rates in Acute Otitis Media
Antibiotic Haemophilus Pneumococcus
Amoxicillin 28% 5%Augmentin 22% 6%Cefaclor 38% 18%Cefuroxime 15% 8%Cefprozil 53% 8%Cefixime 3% 32%Azithromycin 80% 6%Placebo 25-50% 75-85%
Recommended Antibiotic Therapy of Acute Otitis Media
First Line Amoxicillin (80-90 mg/kg/day; Q 8-12 hours)
Second Line Augmentin (80-90 mg/kg/day; Q 8-12 hours)
Cefuroxime (30 mg/kg/day; Q 12 hours)
CDC Working Group on DRSP-AOM, 1998
Individualizing Therapy of Acute Otitis Media
5 days of therapy
Older childSummer monthsOtitis-free (or poor) pastMild episodePrompt improvement
10 days of therapy
Younger childWinter monthsOtitis-rich pastSevere episodeSlow improvement
The diagnosis of acute bacterial sinusitis should be based on clinical criteria in children who present with upper respiratory symptoms that are either persistent or severe.
Suspect Acute Bacterial SinusitisPersistent Symptoms
10 – 30 daysNasal discharge (any quality)Daytime cough (worse at night)Fever (variable)Headache & facial pain (variable)
Severe Symptoms Temperature > 39o
Purulent nasal discharge, 3-4 days
Etiology of Acute Sinusitis
Streptococcus pneumoniae Nontypable Haemophilus influenzae Moraxella catarrhalis
Therapy of Acute Sinusitis
Amoxicillin 45-90 mg/kg/day
Alternatives: cefuroxime, cefpodoxime, cefdinir, clarithromycin, azithromycin
Etiology of Pneumonia
Majority of cases are viralIf non-viral, etiology depends on age of patientIn neonate, consider causes of sepsisIn infant, also consider Staphylococcus aureusIn toddler *, consider Pneumococcus and HaemophilusIn school aged child, consider Mycoplasma
* If incompletely vaccinated
Determinants of Therapy of Pneumonia
Age of hostLaboratory investigationsSeverity of infection
Etiology of Septicemia
Neisseria meningitidisStreptococcus pneumoniae *Haemophilus influenzae type b *Staphylococcus aureus, if adolescent
* if incompletely vaccinated
Therapy of Septicemia
Cefotaxime150 mg/kg/day; Q 6 hours
if adolescent, Nafcillin
150 mg/kg/day; Q 6 hours
Etiology of Bacterial Meningitis
Neisseria meningitidisStreptococcus pneumoniae *Haemophilus influenzae type b *
* if incompletely vaccinated
Cefotaxime200 mg/kg/day; Q6 hours
Ceftriaxone100 mg/kg/day; Q12 hours
Vancomycin ± rifampin60 mg/kg/day; Q 6 hours20 mg/kg/day; Q12 hours
Therapy of Bacterial Meningitis
Etiology of Cellulitis
Streptococcus pyogenes Staphylococcus aureus
Therapy of Cellulitis
Nafcillin150 mg/kg/day; Q 6 hours
Penicillin100,000 Units/kg/day; Q 6 hours
± Clindamycin40 mg/kg/day; Q 6 hours
Etiology of Acute Hematogenous Osteomyelitis
Staphylococcus aureusHaemophilus influenzae *
* If incompletely vaccinated
Nafcillin150 mg/kg/day; Q 6 hours In young, “incompletely” vaccinated,
Cefuroxime150 mg/kg/day; Q 8 hours
Therapy of Acute Hematogenous Osteomyelitis
Etiology of Septic Arthritis
Staphylococcus aureusNeiserria meningitidisStreptococcus pneumoniae *Haemophilus influenzae type b *
* If “incompletely” vaccinated
Cefuroxime150 mg/kg/day; Q 8 hours
Therapy of Septic Arthritis
Etiology of Urinary Tract Infections
EnterobacteriaceaeGroup D streptococci
Sulfisoxazole150 mg/kg/day; Q 6 hours
If pyelonephritis:Ampicillin150 mg/kg/day; Q 6 hoursGentamicin6 mg/kg/day; Q 8 hours
Treatment of Urinary Tract Infections
Etiology of Early Onset Neonatal Sepsis
Group B streptococci Escherichia coli, et al. Listeria monocytogenes
Ampicillin50-200 mg/kg/day; Q 6-12 hours
Gentamicin2.5-7.5 mg/kg/day; Q 8-24 hours
Dose varies according to weight, gestational age, chronologic age, & site of infection
Therapy of Early Onset Neonatal Sepsis
Coagulase negative staphylococci Nosocomial enteric organisms Group B streptococci Listeria monocytogenes
Etiology of Late Onset Neonatal Sepsis
Vancomycin15-30 mg/kg/day; Q 8≥24 hours
Cefotaxime100-150 mg/kg/day; Q 8-12 hours
Dose varies according to weight, gestational age, chronologic age, & site of infection
Therapy of Late Onset Neonatal Sepsis