GUIDELINES FOR TREATMENT OF INFECTIONS IN CHILDREN A. RESPIRATORY TRACT INFECTIONS UPPER RESPIRATORY TRACT INFECTIONS Infection/Condition/likely organism Suggested treatment Preferred Alternative Acute tonsillo-pharyngitis Amoxicillin: Oral Penicillin Child<30Kg- V Group A β hemolytic 20 <27 kg: streptococci BIDx10days 250mg tid Child>30Kg- 250mg TIDx10days Inj Crystalline Penicillin 50,000U/Kg i.v. 4- (if child cannot swallow) ; 27 kg: 1 500mg tid x 10days Erythromycin 10mg/Kg/dose PO 3-4 times x10 days Comment Azithromycin mg/kg ODx5days (IAP Drug Formulary Pg97) Cephalexin: 20 BID OR Cepadroxyl: 15 BID Acute otitis media Streptococcus pneumoniae Haemophilus influenza Moraxella catarrhalis Acute sinusitis Streptococcus pneumoniae Haemophilus influenzae Moraxella catarrhalis Amoxicillin: 40mg/Kg/dose BID x 10days Amoxicillin- 0-20mg/Kg/dose BID x 10-14days Amoxicillinclavulanate (40 of amoxicillin, with 6.4 mg/kg per day of clavulanate [amoxicillin to clavulanate ratio, 14:1] in 2 divided doses) Cefuroxime (15 hrly) Amoxicillinclavulanate (40 of amoxicillin, with 6.4 mg/kg per day of clavulanate 10 day therapy is recommended for younger children and children with severe disease For children >6yrs with mild to moderate disease 5-7days therapy recommended. If no response- Ceftriaxone 50mg/Kg OD x 3days * If S.pneumoniae prevalence >10%,start high dose Amoxicillin 40mg/Kg/dose rly
LOWER RESPIRATORY TRACT INFECTIONS [amoxicillin to clavulanate ratio, 14:1] in 2 divided doses) Cefuroxime (15 hrly x 10-14days Community acquired pneumonia (Outpatient) <5 years old (preschool) >5 years old Community acquired pneumonia (Inpatient) Fully immunized with conjugate vaccines for Haemophilus influenzae type b and Streptococcus Amoxicillin (40 PO hrly) Amoxicillin (40 PO hrly (maximum of 4 g/day) Ampicillin 50mg/Kg/dose IV 6 th hourly Oral Amox + Clauv- (Amox component 40mg/Kg/dose hrly Oral Amoxicillin + Clavulanate (amoxicillin component, 40 rly to maximum dose of 4000 mg/day, eg, one 2000- mg tablet twice daily Ceftriaxone 50 hrly* Or For children with presumed bacterial CAP who do not have clinical, laboratory, or radiographic evidence that distinguishes bacterial CAP from atypical CAP, a macrolide can be added to a b-lactam antibiotic for empiric therapy *Add Vancomycin 15mg/Kg/dose or Clindamycin 10mg/Kg/dose for
pneumoniae; local penicillin resistance in invasive strains of pneumococcus is minimal Ampicillin 50mg/Kg/dose IV Cefuroxime 50mg/Kg/dose th hourly suspected CA- MRSA Not fully immunized for H. Influenzae type B and S. pneumoniae; local penicillin resistance in invasive strains of pneumococcus is significant Amox- 40mg/Kg/dose hrly OR Ceftriaxone 50 hrly* Or Cefuroxime 50mg/Kg/dose th hourly Atypical pneumonia Bronchiolitis RSV,Parainfluenza virus, adenovirus Azithromycin oral (10 mg/kg on day 1, followed by 5 mg/kg/day once daily on days 2 5) None* Oral Clarithromycin (7.5 hrly for 7-14 days) or oral Erythromycin (10 QID) *If infiltrates are present on chest Xray treat as pneumonia B. CARDIOVASCULAR INFECTIONS Infection/Condition/likely Suggested treatment organism Preferred Infective endocarditis Inj. Crystalline empirical/due to penicillin 50,000 Penicillin- U/Kg/dose i.v every Susceptible 4- (Max Streptococcus 1million Units/day) viridans x 4weeks Plus Inj. Gentamicin 3 mg/kg hrly x 2weeks Alternative Inj. Ceftriaxone 100 hrly (Max 2gm) Plus Inj. Gentamicin 3 mg/kg hrly Comment Treatment duration is 4weeks when Ceftriaxone or Crystalline Penicillin is used alone and 2weeks when combined with Gentamicin. 2week regimen not indicated in Cardiac and Extra
OR Vancomycin 15 hrly x 4weeks cardiac abscess. Vancomycin regimen recommended only for patients unable to tolerate Ceftriaxone or Cryatalline Penicillin Infective endocarditis due to Enterococcus sp. S. viridans resistant to penicillin Culture negative Infective endocarditis MSSA MRSA Inj Crystalline Penicillin 50,000 U/Kg/dose 4hrly OR as continuous infusion Plus Inj Gentamicin 3mg/Kg hrly x 6weeks Inj Ceftriaxone 100mg/Kg dose (Max 2gm) hrly Plus Inj Gentamicin 3mg/Kg/dose hrly Inj. Cloxacillin 50 with optimal addition of Inj Gentamicin 3mg/kg hrly x 3-5days Inj. Vancomycin 15 hrly Inj. Vancomycin 15 hrly Inj Cefazolin 35mg/Kg/dose hrly x 6weeks with optimal addition of Inj Gentamicin 3mg/Kg hrly x 3-5days Vancomycin regimen recommended only for patients unable to tolerate Crystalline Penicillin or Ceftriaxone Treatment duration is 6 weeks for endocarditis of prosthetic valves Treatment duration is 6 weeks C.GASTROINTESTINAL INFECTIONS Infection/Conditi Suggested treatment on/likely organism Preferred Alternative Acute Antibiotics not gastroenteritis recommended (Usually viral eg. Rotavirus) Zinc- 20 mg/day in children > 6 Ciprofloxacin15 Comment Oral rehydration is the cornerstone of treatment
Non typhoidal Salmonella Bacillary dysentery ( Shigella spp) months; 10mg <6 months; for 14 days No antibiotic required except in severely malnourished child, neonate or if sepsis suspected Ceftriaxone 50mg/Kg hrly IV Most mild infections resolved spontaneously without antibiotics Children <2years- Trimethoprim/Su lphamethoxazole (TMP: 4 BID x 5-7 days OR Tab Cefixime 4 hrly x 7days hrly x 5days (not required) Inj Cefotaxime 30mg/Kg/dose hrly x 5days Inj Ciprofloxacin 15mg/Kg/dose hrly x 3days (WHO recommendation) Oral rehydration and zinc are the cornerstones of treatment; continue breast feeds and normal diet Continue feeding and add zinc Supplementati on Zinc- <6months: 10mg >6months: 20mg x 14days If sick: Ceftriaxone 50 mg/kg/h for 5days Cholera Ciprofloxacin single dose 30mg/ kg maximum 1 g Doxycycline (adults and older children): Above years, doxycycline 5 mg/kg to be preferred Erythromycin.5 4 times a day 3 days (up to 250 mg 4 times a day 3 days) Prompt rehydration essential, antibiotic therapy is only adjunct to rehydration
300 mg given as a single dose or Tetracycline.5 4 times/day 3 days (up to 500 mg per dose 3days) Giardiasis Metronidazole 5 hrly x 5days Tinidazole >3 yr: 50 mg/kg single dose Nitazoxanide 1-4yr: 100 mg (5 ml) bid for 3 days 4-yr: 200 mg (10 ml) bid for 3 days > yr: 500 mg bid for 3 days Metronidazole 15 mg/kg/day in 3 divided doses for 5-7 days Azithromycin, Trimethoprimsulfamethoxazole and ciprofloxacin, are also effective Albendazole 400mg PO X 5days Nitazoxanide 1-4yrs- 100mg bd x 3days 4-yrs- 200mg bd x 3days Adol- 500mg bd x 3days Albendazole >6 yr: 400 mg once a day for 5 days Furazolidone 6 mg/kg/day in 4 divided doses for 10 days Quinacrine 6 mg/kg/day in 3 divided doses for 5 days Cephalosporin s and aminoglycosid es should not be used, even if in vitro tests show strains to be sensitive. Zinc should be given as soon as vomiting stops Liver abscess (amoebic) Entamoeba histolytica Liver abscess (pyogenic) Gram-ve, Anaerobic, S. Metronidazole 10 hrly x 10-14 days Ampicillin 50 Inj Cefotaxime 50 Inj Metronidazole Amoebic abscess tend to be solitary lesion. Consider surgical drainage if needed Initially broad spectrum antibiotics; should
aureus Gentamicin 5mg/kg hrly Metronidazole 10 hrly Empirical initial antibiotic regimens include Ampicillin/ Sulbactam or Piperacillin/Tazo bactam 10 hrly then be narrowed, based on the culture results of the abscess; IV for 2-3 weeks followed by oral therapy to complete a 4-6 week course Surgical drainage is needed in most cases Acute cholangitis (Gram negative, anaerobes, gram positive) Peritonitis (Primary) Strep. Pneumoniae, gram-neg organisms Ampicillin 50 Gentamicin 7.5mg/Kg IV o.d Metronidazole 10 hrly for 7 days Ampicillin 50 Gentamicin 7.5mg/Kg IV o.d x 7days Cefotaxime 50 Metronidazole 10 hrly Cefotaxime 50 hrly If Cholangitis due to gall stones: consider clearance of obstruction by ERCP D.SEPSIS SYNDROMES Infection/Conditi Suggested treatment on/likely organism Preferred Alternative Comment
Enteric fever Ampicillin/Amox ycillin 50 PO x 10-14 days Or [Trimethoprim/S ulphamethoxazol e 4/20 BID] Cholorampenicol 25mg/Kg/dose 6- hrly Oral- Tab. Cefixime 10 hrly (max.400mg/day) x 10-14 days Or Parenteral- I.V. Ceftriaxone 25-35 hrly x 10-14 days Or *Ciprofloxacin 10 PO BID *Quinolones need to be used with caution in children due to possible arthropathy and rapid development of resistance. Community acquired sepsis Ceftriaxone 50 hrly x 14 days Cefotaxime 50 IV 4- X 14days Intravenous catheter related sepsis Cloxacillin 100mg/Kg/day IV in 4 bdivided doses + Gentamicin 5mg/Kg IV o.d Gentamicin 7.5mg/Kg IV o.d Vancomycin 30mg/kg/day IV in 3 divided doses + Gentamicin 5mg/kg IV o.d Modify therapy based on susceptibility report; consider line removal for persistent positive cultures, fungal infection or gram negative infection E. CENTRAL NERVOUS SYSTEM INFECTIONS Infection/Conditi on/likely organism Acute bacterial meningitis Suggested treatment Preferred Alternative Ceftriaxone 50 hrly x 7-14days Cefotaxime 50 IV X 7-14 days In neonatal and resistant bacterial meningitis other antibiotics to be advised. Comment If culture grows Streptococcus pneumoniae, susceptible to penicillin,treat
Herpes Simplex encephalitis Acyclovir: weeks- years old: 500mg/m2 qh If > years olds: 10mg/kg IV qh Duration: for 14-21 days Brain Abscess Ceftriaxone 50 hrly And Metronidazole 15mg/kg IV stat then 7.5mg/kg IV qh Need for Vancomycin as add on in primary empirical drug also to be discussed If there is history of Neursurgery, trauma or sinusitis terapy should include Ceftazidime 50mg/Kg/dose hrly, Vancomycin 15mg/Kg/dose and Metronidazole 7.5mg/Kg hrly ment may be modified to IV Crystalline penicillin(2-4lac units/kg/day every 4-6 hrs for 10-14days Duration of antibiotic would depends on response by neuroimaging; 4- weeks may be needed) F. SKIN AND SOFT TISSUE INFECTIONS Infection/Conditi on/likely organism Suggested treatment Preferred Alternative Cephalexin 10mg/Kg/dose Amox+Clauv 25mg/Kg/dose hrly Erythromycin 10mg/Kg/dose Comment
G. URINARY TRACT INFECTION Cephalexin 25mg/Kg/dose hrly Amox+Clav 25mg/Kg/dose hrly Cefixime 5mg/Kg/dose hrly Inj Cefotaxime 50mg/Kg/dose hrly OR Inj Amikacin 15mg/Kg od <3months with complicated UTI- Admit and treat For Infants treat for 10-14days and others 7-10days H. NEONATAL INFECTIONS
*Reference NEOFAX 2011 Thomson Reuters th Edition NECROTISING ENTEROCOLITIS AMPICILLIN DOSE & ADMINISTRATION: 25 TO 50mg/kg per dose by slow push 100 when treating meningitis & severe group B streptococcal sepsis PMA (WEEKS) POSTNATAL (DAYS) INTERVAL (HOURS) < 29 0-2 >2 30-36 0-14 >14 37-44 0-7 >7 45 ALL 6 GENTAMICIN PMA (WEEKS) POSTNATAL (DAYS) DOSE (mg/kg) INTERVAL (HOURS) 29 * 0-7 -2 29 5 4 4 4 36 30 to 34 0-7 4.5 4 36 35 ALL 4 * or significant asphyxia, PDA, or treatment with indomethacin METRONIDAZOLE PMA (WEEKS) POSTNATAL (DAYS) INTERVAL (HOURS) 29 0-2 >2 4 30-36 0-14 >14 37-44 0-7 >7 45 ALL Loading dose : 15 mg/kg PO or IV infusion by syringe pump over 60 minutes Maintenance dose: 7.5 mg/kg PO or IV infusion over 60 minutes
CONGENITAL SYPHILLIS BENZYL PENCILLIN PMA (WEEKS) POSTNATAL (DAYS) INTERVAL (HOURS) 29 0-2 >2 30-36 0-14 >14 37-44 0-7 >7 45 ALL 6 Meningitis : 75,000 to 100,000 units/kg per dose IV infusion over 30 minutes Bacteremia : 25,000 to 50,000 units/kg per dose IV infusion over 15 minutes HERPES SIMPLEX ACYCLOVIR 20 mg/kg per dose Q hrs IV infusion over 1 hr Increase dosing interval in premature infants <34 weeks PMA or patients with significant renal impairment/ hepatic failure EARLY ONSET SEPSIS BENZYL PENCILLIN Meningitis : 75,000 to 100,000 units/kg per dose IV infusion over 30 minutes Bacteremia : 25,000 to 50,000 units/kg per dose IV infusion over 15 minutes PMA (WEEKS) POSTNATAL (DAYS) INTERVAL (HOURS) 29 0-2 >2 30-36 0-14 >14 37-44 0-7 >7 45 ALL 6 CEFOTAXIME 50 mg/kg per dose iv infusion by syringe pump over 30 minutes,or IM PMA (WEEKS) POSTNATAL (DAYS) INTERVAL (HOURS) 29 0-2 >2 30-36 0-14 >14 37-44 0-7 >7 45 ALL 6
GENTAMICIN PMA (WEEKS) POSTNATAL (DAYS) DOSE (mg/kg) INTERVAL (HOURS) 29 * 0-7 -2 29 5 4 4 4 36 30 to 34 0-7 4.5 4 36 35 ALL 4 * or significant asphyxia, PDA, or treatment with indomethacin LATE ONSET SEPSIS CEFOTAXIME 50 mg/kg per dose iv infusion by syringe pump over 30 minutes,or IM PMA (WEEKS) POSTNATAL (DAYS) INTERVAL (HOURS) 29 0-2 >2 30-36 0-14 >14 37-44 0-7 >7 45 ALL 6 ** REFERENCE: Neonatal Formulary : Drug Use in Pregnancy and First Year of Life 5 th Edn BMJ books. CONGENITAL TOXOPLASMOSIS IN INFANCY : give an oral loading dose of 1mg/kg of pyrimethamine twice a day for 2 days followed by maintanence treatment with 1 mg/kg once a day for weeks,if there is evidence of congenital infection.treatment with 50 mg/kg of oral sulfadiazine once every hours should be started at the same time.check weekly for possible thrombocytopenia,leucopenia and megaloblastic anemia