Paediatric Empirical Antimicrobial Guidance for Infections in Hospital

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. Author: NHS Fife Antimicrobial Management Team 1

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 Author: NHS Fife Antimicrobial Management Team 2

Community Acquired Sepsis Community-acquired sepsis in children >28 days old 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 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 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. Author: NHS Fife Antimicrobial Management Team 3

Central Nervous System Infections Please refer to meningitis research foundation algorithm http://www.meningitis.org/assets/x/53067 Meningitis (neonate and child 3 mths old) Empiric Treatment: Early-onset (up to 28 days) Benzylpenicillin IV Gentamicin IV Seek Microbiology advice Late onset (after 28 days) If organism unknown, treat for 14 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. Group B Streptococcus: Benzylpenicillin IV Gentamicin IV Seek Microbiology advice Gram-negative bacilli Listeria monocytogenes: Amoxicillin IV Gentamicin IV Seek Microbiology advice 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. 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. Author: NHS Fife Antimicrobial Management Team 4

Meningitis (>3 months to 16 years) Obtain travel history and consider adding Vancomycin IV if recently overseas or prolonged or multiple antibiotic exposure within last 3 months. 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. 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. Viral encephalitis Aciclovir IV (as per local protocol) Minimum 21 days 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). Author: NHS Fife Antimicrobial Management Team 5

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. Acute viral gastroenteritis Acute Bacterial gastroenteritis Enteric fever (Typhoid and Paratyphoid) Mild/Moderate Clostridium difficile infection Severe Clostridium difficile infection (immunocompromised, or abdominal tenderness, or fever, or raised WBC or declining renal function) Pseudomembranous colitis Antimicrobial therapy seldom indicated unless systemic invasion is suspected. Consult Microbiology before starting antibiotics. Salmonella: Shigella / Campylobacter: Ciprofloxacin oral If treatment required: Metronidazole oral Vancomycin oral Vancomycin oral (high dose) Metronidazole IV 10-14 days for cefotaxime IV 5 days for oral ciprofloxacin Treat bacteraemia and severe infection treat for 10-14 days. 10 to 14 days. Stop at day 10 if symptoms resolved. 10 to 14 days. Stop at day 10 if symptoms resolved. Seek microbiology advice 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. Beware of complications e.g. osteomyelitis, meningitis. If these present, treatment should be given for longer. Seek Microbiologist advice Stop all concurrent antibiotics if possible. Seek microbiology advice if antibiotics cannot be stopped. If patient unable to tolerate oral or NG vancomycin, give metronidazole intravenously. Do not use vancomycin IV. Seek urgent GI or surgical review Author: NHS Fife Antimicrobial Management Team 6

Community acquired peritonitis Hospital acquired peritonitis Ascending cholangitis and acute cholecystitis Metronidazole IV Seek Microbiology advice Metronidazole IV Seek Microbiology advice Minimum 7 days Concomitant surgical management is important. Patients with complicated peritonitis, previously treated with broad-spectrum antibiotics are at risk of infection with multiresistant organisms. In addition empirical antifungal therapy (e.g. fluconazole) may be considered for patients with complicated postoperative intraabdominal infections. 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 Peritonitis associated with dialysis Metronidazole IV Seek Microbiology advice Seek specialist advice. 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. Author: NHS Fife Antimicrobial Management Team 7

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 Mild Community-acquired pneumonia (CAP) or pneumonia within 48 hours of admission Severe CAP or presents also with influenza: Amoxicillin oral* Clarithromycin oral *Note: consider adding clarithromycin if mycoplasma pneumonia suspected Co-amoxiclav IV 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/respir atory/seasonal-influenza/antiviral-guidanceseason-15-16-v2.pdf Community aspiration pneumonia Hospital-acquired pneumonia (>48 hours after admission) Co-amoxiclav IV Metronidazole IV Review risk of MRSA infection and available microbiology/virology results and seek advice. Hospital aspiration pneumonia (>48 hours after admission) Metronidazole IV Review risk of MRSA infection and available microbiology/virology results and seek advice. Author: NHS Fife Antimicrobial Management Team 8

Bronchiectasis, acute exacerbation Co-amoxiclav oral or IV Seek Microbiology advice 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 Antibiotics not routinely recommended (RSV) infection 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. Author: NHS Fife Antimicrobial Management Team 9

Musculoskeletal system Skin and soft tissue infections In skin and soft tissue infections surgical review is often useful. Tetanus prophylaxis should not be forgotten. 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 Necrotising fasciitis Co-amoxiclav IV Ciprofloxacin IV Clindamycin IV Meropenem IV (Maximum dose) Clindamycin IV (Maximum dose) 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). 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 Clindamycin IV Vancomycin 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. Clindamycin IV Author: NHS Fife Antimicrobial Management Team 10

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 Human/Cat/Dog bite Co-amoxiclav IV If MRSA risk: + Vancomycin IV Vancomycin IV + Ciprofloxacin IV + Metronidazole IV 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 Send a wound swab for culture prior to initiating treatment. Further therapy should be guided by laboratory results. 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. Author: NHS Fife Antimicrobial Management Team 11

Acute bone and joint infections Take blood cultures and send joint aspirates for culture before starting empirical antibiotic therapy. Septic arthritis or Acute osteomyelitis Empirical therapy: Age: 0-3 months old: Contact Microbiology 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 In all cases seek specialist orthopaedic advice at the outset. Do not start antibiotic therapy until appropriate samples have been obtained for culture. Age: >3 months: Flucloxacillin IV Clindamycin IV Clindamycin IV 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 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 Author: NHS Fife Antimicrobial Management Team 12

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. 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. Central venous catheters, nontunnelled (including arterial cannulae) Discuss with the child s specialty service Vancomycin IV 10 days from line removal Discuss with Microbiology Author: NHS Fife Antimicrobial Management Team 13

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. UTI in children < 3 months old Seek senior paediatric advice 1 st line Co-amoxiclav IV 2 nd line (see notes) Amoxicillin IV plus Gentamicin 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. Author: NHS Fife Antimicrobial Management Team 14

Complicated upper UTI with systemic symptoms (including pyelonephritis) in children > 3 months old 1 st line Co-amoxiclav IV 2 nd 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 noncompliance 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. Author: NHS Fife Antimicrobial Management Team 15

Eye infections 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. For all other eye infections seek ophthalmology advice Ear Nose and Throat Infections See NHS Fife Primary Care Antibiotic Guidance Common Viral Infections 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. Chickenpox Shingles Not usually required If required, Aciclovir (oral if well, IV if immunocompromised) Consider oral Aciclovir (if severe, or an immunocompromised patient: Aciclovir IV) 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. Minimum 7 days 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 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. 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. Author: NHS Fife Antimicrobial Management Team 16

Prophylaxis Antibiotic prophylaxis for selected medical conditions Condition/ 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 Author: NHS Fife Antimicrobial Management Team 17

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 Author: NHS Fife Antimicrobial Management Team 18

Ear Nose and Throat Surgery Procedure Recommendation Penicillin allergy and / or MRSA infection / colonisation Ear surgery Nil required (clean / clean contaminated) Tonsillectomy Adenoidectomy Routine nose, sinus and endoscopic sinus surgery Head and neck surgery (clean, benign) 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 Author: NHS Fife Antimicrobial Management Team 19