Antibiotic Choices for Infections which Require Hospitalization

Rodolfo E. Bégué, MD

Chief, Infectious Diseases

Pediatrics, LSUHSC

rbegue@lsuhsc.edu

Infections which require hospitalization

Examples:r/o sepsismeningitis / encephalitisbrain abscess / orbital cellulitispneumonia / endocarditisacute abdomenurinary tract infection bone & jointskin & skin structures

Fever r/o sepsis

• Hyperthermia or hypothermia

• Tachycardia

• Tachypnea

• Leukocytosis or leukopenia

• Toxicity = clinical picture - lethargy - hypoperfusion - hypoventilation, hyperventilation or cyanosis.

Sepsis work-up

• Cell Blood Count (CBC) Blood Culture

• Urine analysis Urine Culture

• Chest roentgenogram

• Stool

• NPA

• Lumbar puncture CSF Culture

• (CRP, Procalcitonin)

Etiologies of Sepsis

< 1 month of age

• Group B Streptococcus

• Escherichia coli

• (Listeria monocytogenes)

1-3 months of age

• Streptococcus pneumoniae (↓)

• Group B Streptococcus

• Neisseria meningitidis

• Salmonella spp

• (Haemophilus influenzae b)

• (Listeria monocytogenes)3-36 months of age

• Streptococcus pneumoniae (↓)

• Neisseria meningitidis

• (Haemophilus influenzae b)

Antibiotics for a child with r/o Sepsis

Empiric Antibiotic Treatment:< 1 month: Ampicillin + Gentamicin

Ampicillin + Cefotaxime

1-3 months: Ampicillin + Cefotaxime

> 3 months: Cefotaxime

(Vancomycin?)

x 7-14 days

Is it a contaminant?

• 1 vs >2 positive culture

• Pathogen vs no pathogen

• Symptoms vs no symptoms

• Timing (< 24 h vs > 24 h)

• Plate vs broth (“thio”)

Central Line Infection

• Central & Peripheral Blood Culture

• Gram-positive, Gram-negative, Fungi

• If possible, change line(Staph, Enteroc, GN, Fungi, Mycobact)

• vs treat through line

• If line out: ~ 1 weekIf line in: ~ 2 weeks

• Antibiotic lock

Bacterial Meningitis

• Diagnosis: LP, LP, LP

• Should I do an LP?

• Increased intracranial pressure

• Prior antibiotics

• “Bloody tap”

Bacterial Meningitis: Treatment

• Neonate: Amp+Gent / Amp+Cefotax

• Older child: cefotaxime plus vancomycin

• Modify according to susceptibilities:penicillincefotaximevancomycin plus cefotaxime

• Corticosteroids (?)

• Rifampin (?)

Aseptic Meningitis

• Viral (enterovirus vs others)

• “Partially treated”

• Other causes only on special populations

Encephalitis

• Not bacterial

• HSV Enterovirus Arbovirus (WNV) EBV, CMV, etc

• ADEM

HSV Encephalitis

Acyclovir:

60 mg/kg/d div q 8 hr

750 mg/m2/d div q 8 hr

x 21 days IV

Brain abscess

Source:

• Proximity: middle ear, sinuses

• Meningitis

• Hematogenous

• Penetrating: wound, surgery

Brain abscess

Triad:

• Headache

• Focal neurologic findings

• Fever

Treatment:

• Surgery

• Antibiotics: Cefotax + Vanco + (Metro)

• for 4-8 weeks (IV)

Orbital Cellulitis

Triad:

• Proptosis

• Decreased eye movement

• Pain on eye movement

Orbital Cellulitis

Treatment:

• Antibiotics:Cefotax + Vanco + (Metro) Cefotax + Clindax 10-14 d IV and 7-14 d PO

• Surgery (ORL, Ophthalmology)

HSV Keratitis

Management:

• With an ophthalmologist

• antivirals:1-2% trifluridine1% iododeoxyuridine3% vidarabinex 14-21 days

• topical corticosteroids contraindicated

• No need for systemic acyclovir

Pneumonia

• Viral:Influenza, RSV

• BacterialStreptococcus pneumoStaph aureusGroup A Streptococcus

• TB

• ChlamydiaMycoplasma

• Fungal

Empiric Treatment for Pneumonia

• If sick enough to require admission (assuming viral panel negative), the regular r/o sepsis regimen is usually OK:• Ampi + genta / Ampi + cefotax / Cefotax• Usually add a macrolide (erythro or azithro)• Add Vancomycin if VERY sick or necrotizing• Others (TB, Gram-negative, PCP, fungal) only if a good

reason to suspect

Endocarditis

• Acute Staph (MRSA)

• Subacute viridans Strept

• Antibiotics: Vanco + gentamicin Penicillin + gentamicin

• X 2 w, 4-6 w

• Surgery (?)

Pericarditis

• “Purulent pericarditis”

• Strept PneumoStaph aureus (MRSA)

• Antibiotics: Ceftriaxone + Vancomycin

• X 4 weeks

• Surgery (?)

Acute AbdomenDiagnosis:

• Clinical

• Imaging (XR, US, CT)

Treatment

• Surgery

• Antibiotics

Mild-moderate Severe

Ampi/sulb, Ticar/clav Piperac/Tazobactam

Imipenem, Meropenem, Ertapenem

Cefazolin or cefuroxime+ metronidazole

Cefotax, ceftriax, ceftaz, cefepime+ metronidazole

Ampi + genta (Tobra) + Metronidazole (Clinda)

Cipro, levoflox, gatiflox+ Metronidazole

Aztreonam + Metronidazole

For 5-7 days IDSA. CID 2010;50:133-64

PO Cipro/Metro or Amox/Clav x 14-21 d

Urinary Tract Infection

• Always suspect in febrile children < 2 yrs of age

• Dx of UTI requires a UCx (bag-specimen not good)

• UA (WBC), dipstick OK as a guide, especially in combination

• Gram stain (“unspun” urine)

Etiology

• Escherichia coli

• Enterococcus

Urinary Tract Infection

Follow-up

• US, VCUG

• DMSA scan

• Consider prophylaxis

Inpatient Treatment

• Cefotaxime or Ceftriaxone

• Ampicillin + gentamicin

Osteomyelitis

• Staph aureus

• (Others in especial populations)

• ClindamycinVancomycinLinezolid

• X 4 weeks (IV/PO)

• Surgery

Septic arthritis

• Fever, joint pain/swelling, decreased ROM

• Diagnosis: clinical, XR (hip), US, arthrocentesis, CT (SI)

Septic arthritis

Treatment:

• Aspirate vs Surgery: hips, shoulders

• Antibiotics:Vancomycin (Clinda, Oxacillin) + cefotaxime (cefuroxime)

• x 3 weeks (IV/PO)

Etiologies:

• Staph aureus

• Streptococcus (GAS, Strept pneumo)

• Kingella kingaeSalmonella

• Neisseria (GC, N. meningitidis)

• (H. influenzae)

Puncture wounds (foot)

Etiology

• Staph aureus (~ 3 d)

• Pseudom spp (~ 7 d)

• Mycobacteria (~ 2-4 w)

Treatment

• Wound careTetanus vaccineAnti-Staph antibiotics

• If no responseSurgical exploration → cultureCeftazidime → ciprofloxacin (for 2 w)

Skin and Soft Tissue

• Etiology:Group A Streptococcus Staphylococcus aureus (MRSA)(Strep pneumo / Hib)

• Treatment:Vancomycin or Clindamycinadd rifampin?linezolid??

• Drain any abscess

Any Question?