ANTIBIOTIC USE

IN CHILDREN
Panit Takkinsatian, MD.
Pediatric department, Faculty of Medicine
Srinakharinwirot University
Antibiotic groups

■ Penicillin
■ Cephalosporin
■ Carbapenam
■ Macrolide
■ Aminoglycoside
■ Fluoroquinolone
■ Glycopeptide : vancomycin
■ Other
Mechanism of Action
Mechanism of action Antibiotics
A
Inhibit cell wall synthesis
- Inhibit crosslink of peptidoglycans penicillin Bacteriocidal
cephalosporin
carpapenam
- Inhibit peptidoglycan synthesis by vancomycin Bacteriocidal
other pathway
Increase cell membrane permeability polymycin (colistin) Bacteriocidal
Mechanism of Action
Mechanism of action Antibiotics
Inhibit protein synthesis
~thromyair
- 50s ribosome macrolide Bacteriostatic
chloramphenicol
linesolid
- 30s ribosome aminoglycoside Bacteriocidal
tetracycline Bacteriostatic
Inhibit nucleotide synthesis trimethoprim- Bacteriostatic
(folic acid biosynthesis) sulfonamide
(bactrim)
Inhibit DNA gyrase fluoroquinolone Bacteriocidal
Significant Side Effects
Gastrointesinal side effect
Neomycin Villus damage (mal-absorption)
Clindamycin, lincomycin, macrolide Pseudomembranous colitis
Most antibiotic (except metronidazole)
-Vancomycin Xr
Renal side effect T: Pseudomembranous colitis

Aminoglycoside, vancomycin · Colistin Tubular damage -> AKI : ros monitor BUN, Cu.

Penicillin Interstitial nephritis

Other side effect

↓evofloxacin
at
Prolong
Fluoroquinolone arthropathy in children
-
-

Ceftriaxone fucatwion<1 row) NB VS high protein bound CHUCOUP. -> Free form bilinking
Chloramphenicol gray baby in newborn
Tetracycline teeth discoloration and enamel
(Doxycycline Primal hypoplasia in fetus & children
PENICILLIN
Spectrum of penicillin

Form Spectrum
-

Natural penicillin IV form : penicillin G (Aquous) Most GPC arrow stup......

Oral form : Penicillin V Some GNR (no BL) not Betalactamase
IM form : procaine, benzathine Anaerobe
↳fat.: MTW IV M
penicillin Spirochete : syphilis, leptospirosis
Aminopenicillin Oral form : Amoxycillin Like natural pencillin
IV form : ampicillin More GNR (H. influ, E.coli) 3 framt, -
wal, No, y
UT I

Enterococci
~veee* -
alciou
Anti-staph-penicillin IV, oral form : Most GPC (MSSA, MSCNS, Strep.) :of skin ·

Dicloxacillin, cloxacillin No activity against *

GN, enterococci
Spectrum of penicillin

Form Spectrum
Anti-pseudomonas IV form : Most GPC (incl. MSSA, MSCNS, enterococci)
- ESBL
penicillin Piperacillin GN (incl. pseudomonas, bactalactamase
(always combine with producing) a Metronidazole anion C. diff
Tazobactam) Anaerobe
--(except C. difficile)
Ticarcillin Like PIP/Tazo (except enterococci)
 ordof
Betalactamase inhibitor PWR CNS ... Blactamase inh.

↑
plactamase inhi Unasyrbractor inhibit

Amoxicillin/clavulanate Ampicillin/sulbactam Piperacillin/Tazobactam Cefoperazone/sulbactam

his oral listusnil sai IV

Gram +ve
MSSA, MSCNS + + + +
MRSA,MRCNS - - - -
+
Enterococci + + -
Gram –ve
Enterobacteriaceae + + + +
Pseudomonas - - + +
H. Influenzae + + + +
M.Catarhalis + + + +
Anaerobe
C.Difficile - - - -
B.fragilis +/- +/- +/- +/-
Amoxicillin/clavulanate preparation :(p3-s0 mhday)

Amox : clav ratio Preparation Remark

2-4:1 125:31, 250:125, 500:125 More GI S/E
7:1 7 Clare and
=
ow Stap * 200:28, 400:57 Good coverage against MSSA

clar z
Less GI S/E ~Claudio -0.3 meg (fabrosis)
14:1 600:43
High dose usage only (against ESBL)run

Loon Pt, binding. In penicillin

except: H.inf, Ecoli: doms pluctamase

Use bid instead of tid in URI, OM, sinusitis

To cover DRSP as well as H.influ and M.cat (ESBL strain)
Increase dose amoxycillin to 80-100 MKDay
Keep clavulanate around 6.4 MKDay
The preparation of 4:1 is needed for S. aureus
CEPHALOSPORIN
 Spectrum of Cephalosporin
Generation ATB Spectrum
1st generation IV : Cefazolin ↑rousin palbitic in Cluxa
GPC : (Strep, Staph, except
Oral : Cephalexin, Cefadroxil Enterococci)
GNR : (less) E.coli
2nd generation IV : Cefuroxime, Cefoxitin like 1st gen
Oral : Cefuroxime, Cefprozil, Cefaclor more GNR (esp. H.influ, M.cat)
Cefamycin >> some GNR, most anaerobes
3rd generation IV : Cefotaxime, Ceftriaxone, GPC (esp. cefotaxime), but not
Ceftazidime, Cefoperazone nwpseudomous,
↓ as good as 1st gen),
Oral : Cefixime, Ceftibuten, Cefpodoxime, most GNR
Cefdinir, Cefditoren
Cefoperazone always combine with sulbactam (sulcef™)

Parenteral: with P.aeru ginosa>> Ceftazidime, Cefoperazone

Oral: without GPC >> Cefixime, ceftibuten
Cefotaxime vs Ceftriaxone VS Ceftazidime
and let's enumer
~ Oram #
Cefotaxime Ceftriaxone
■ Better coverage for GP ■ Once daily dosing ↑usinws/on
■ Excrete via renal :Pt.Perios Vow close ■ Limited use in newborn because of
.:sarknorewen albumin binding
– Renal adjustments are – Jaundice
needed
■ No renal adjustment needed Parmosfumingo

Ceftazidime -8 only
• Good coverage for GN and P. aeruginosa
• -No add P es.dindymycin,
No coverage for GP
↑ O Metronidazole.
-
All of them have no coverage for anaerobe & Enterococci
Oral Cephalosporin
Coverage
1st gen : cephalexin GP (Extensively) (MSSA, MSCNS, Strep.)
&ins-you passan and didoxa GN : no
2nd gen : cefuroxime, cefprozil GP : MSSA, MSCNS, Strep.
GN : H. influenza, M.catarhalis, enterobactericeae (no ESBL)
3rd gen GP
GN : (extensively) (except P.aeruginosa)
~ set span
Cefixime, ceftibuten A coverage
No GP
Cedinir GP and GN coverage
Cefditoren Enhanced GP coverage (DRSP)

All oral cephalosporin has no coverage for enterococci, pseudomonas and anaerobe.
Indications for Oral Cephalosporin

Indication Cepalexin Cefuroxime Cefixime Cefdinir Cefditoren

1st 2 nd 3nd 3nd 3nd
Tonsillitis √ √ x √ √

3
OM/sinusitis x √ x √ √
Pneumonia x √ x √ √
UTI   √ √ √
GI x x √ √ √
Skin & soft tissue infection √ √ x √ √

Too Broad ATB!!

CARBAPENAM
Carbapenam
Coverage Note
Meropenam • Most GPC (except MRSA,
MRSE, VRE)
Imipenam • Most GNR (except
Ertapenam X.malto, B.cepacia) • Except P. aeruginosa &
Acinitobactor spp. Sulperaum
• Anaerobes (except
-

Cellistin
• IM form
C.difficile)
Doripenam

No coverage for : MRSA, MRCNS, VRE

CRE, S.malto, B.cepacia
C.difficile
atypical pathogen : mycoplasma, chlamydia
Carbapenam

Imipenem Meropenam
Spectrum Same Same
Efficacy Better for staph. & enterococci Better for GNR
Betalactamase induction More Less
Limitation Cilastatin --> seizure none
Cimpenen..Partofovir
Pseudomonas : Doripenam > Meropenam > Imipenam
Gram +ve : Imipenam > meropenam, doripenam, ertapenam
Gram –ve : Meropenam, doripenam, ertapenam > Imipenam
LPanow Pseudomonas
MACROLIDES
 Macrolides
Advantage Disadvantage
all cover atypical bacteria GI disturb, CYP450,
(M. pneumo, Clamydia spp., S.typhus, not effective for PRSP
M. typhus)
Erythromycin well-known, cheap qid, most GI disturb,
Hypertrophic &

HPS in newborn
stenosis
Pyrovic
Need long duration of tx (14 d)
& oubalis bid, less S/E
Roxitromycin may be less effective (resistance)
Claithromycin Bid, cover more for GNR Expensive
cover MAC Duration of tx : 10 d
20%
Azithromycin od, short-duration Rx Expensive
I cell o cover MAC Induce resistance (china)
2 Intracellular, Short duration of tx (3-5 d) enfair son
2
90%. Mycoplane
won
Mycoplasma not interfere CYP450
higher intracellular level
Clindamycin
-Potausa Penicillin

so one

■ BacteriostaticOr
■ Lack of Eagle effect
■ Toxin producing inhibition
– TSST-1 in toxic shock syndrome so dueodis toxin (staph

Coverage
GPC : likeor
1st gen cephalosporin
Abdomen
Anaerobe except C. difficile, B. fragilis
No coverage against GNR
Eagle effect : paradoxically reduced antibacterial effect of penicillin at high doses, though recent
usage generally refers to the relative lack of efficacy of beta lactam antibacterial drugs on
infections having large numbers of bacteria.
FLUOROQUINOLONES
Fluoroquinolones
■ Bacteriocidal

■ Concentration dependent with PAE

■ Derivative of nalidixic acid

Drug
Old drugs Norfloxacin, Ciprofloxacin, US FDA :
Ofloxacin Not approved for children
New drugs Levofloxacin, Sparfloxacin, age younger than 18 years
-

old !!
-

gatifloxacin, Moxifloxacin TB
 Old fluoroquinolone : spectrum

Coverage
↓-
Absorption
Norfloxacin GNR (mainly in GI tract)
@ SI
- Low oral bioavailability
.

Ofloxacin GNR (mainly in GU tract)

- higher oral bioavailability
excretion M.Tuberculosis
.:
DUTI Ciprofloxacin GNR including P. aeruginosa findows
A

dapw Pseudomoum
All fluoroquinolone has no coverage for gram positive organism.
New Fluorquinolones in Children

■ Strongly inhibit topoisomerase II (DNA gyrase) and IV --> inhibit DNA

supercoil and separate daughter DNA
■ Metabolite by liver: Cipro, Spar, Trova (exclusive)
■ Mainly renal clearance: Oflox, Levoflox
■ S/E: GI; Trova>Spar>Cipro=Gati>Norflox>Oflox
CNS; Trova>Norflox>Spar>Cipro>Oflox>Gati
Epilepsy; Trova>Cipro>Oflox>Levoflox
Photosens; Spar>Cipro>Norflox=Oflox=Levoflox
 Newer Fluoroquinolones : Levofloxacin
L Tx outs
=
Mosoda by us is

■ L-Ofloxacin (efficacy 30-120 times>D) vii =

M0n0 therapy
■ 2 times higher efficacy than Ofloxacin = For Ba
■ Spectrum as compare to Ciprofloxacin:
- Better for GPC
- Equal for GNR (less for Ps.aerugenosa)
- atypical pathogen : Mycoplasma, chlamydia spp.
■ Clinical Use: GI/GU infection, STD, and other MDR-GNR infection
■ S/E: same as others, less photosensitivity
Newer Fluoroquinolones
Sparfloxacin, Gatifloxacin, Moxifloxacin

■ Spectrum - Good for GPC (=1st gen ceph.) and DRSP

- Remain efficacy for GNR
(not as good as Cipro for Ps.aerugenosa)
- Remain active for atypical bacteria
Mycoplasma, Chlamydia, Legionnaire, Pertussis
■ Clinical Use - Same as current quinolones
plus LRI, sinusitis, skin/soft tissue infections
■ Not approved in children
Travafloxacin was removed due to hepatic failure
AMINOGLYCOSIDE
Aminoglycoside

■ Bacteriocidal
■ Concentration dependent with post antibiotic effect (PAE)
■ Coverage : only for GNR
■ Amikacin > gentamicin : pseudomonas
■ Streptomycin & Kanamycin : spare for TB
*
■ Low penetration in lung, CNS

Pi synergize: Prissier time depentant (Primer, adi

GLYCOPEPTIDE
Glycopeptide

■ Vancomycin, teicoplanin
■ Spectrum : all gram +ve bact. Including MRSA, MRCNS, enterococci,
gram +ve anaerobe
■ Oral form : C. difficile
go 910 anaphy
■ Redman syndrome : anaphylactoid > extend dripping time

Indication for vancomycin level (linear pharmacokinetic)

- Renal failure
- High Vd
- Serious infection (CNS, septicemia)
- Drug interaction
OTHER ANTIBIOTIC
Linezolid

■ Bacteriostatic (inh. Protein synthesis)

■ Oral form only in Thailand (100% bioavailability)
■ S/E : bone marrow suppression

Spectrum
GP : all GP including : MRSA, VISA/VRSA, CONS, VRE,
bacillus spp.
Nocardia, TB
No coverage for GN
Tigecycline

■ Bacteriostatic : inhibit protein synthesis

■ Derivative from tetracycline
■ Not approved in children

Spectrum
GP : most GP including Entercocci, VRE, MRSA
GN : most GN including A. baumannii except Pseudomonas
Anaerobe : B. fragilis, C.difficile
Atypical pathogen : mycoplasma, chlamydia
Colistin

■ Polymyxin E (colistimethate sodium)

■ Concentration dependent
■ Mechanism
– Disrupt cell membrane : bacteriocidal
– Bind & neutralizaed LPS (block effect of endotoxin)
■ Formulation : IV, IM, nebulization
■ S/E : AKI (from ATN), neurotoxicity

Spectrum
GN : esp. MDR A.buamannii, P. aeruginosa
No coverage for GP
Doxycycline
■ Inhibit protein synthesis by binding 30s ribosomal subunit
■ Bacteriostatic
■ Not approved for children aged ⑮
<8 yr
– Dental staining
– Effect on growth

Spectrum
GP : pneumococci, Listeria spp.
GN
Atypical pathogen : mycoplasma, chlamydia, rickettsia
Protozoa : malaria, filaria
Trimethoprim-sulfamethoxazole

■ Bind to dihydrofolate reductase (inh bacterial DNA synthesis)

Use for
UTI prophylaxis
PCP treatment and prophylaxis
Toxoplasma prophylaxis
CA-MRSA ·community aguired MRSA *
1st line for S. maltophilia, B. cepacia, nocardia
 M/C
SINUSITIS
30% 20.1.

S.pneumoniae, H. influenzae, M. catarrhalis

swerom: &Blactamas
pennicillin
(80 100%
(marcos .)
70-80
Basic knowledge of sinusitis

■ Criteria for diagnosis

– Persistent symptom for 10 days of duration
– Severe symptom for 3-4 days
– worsening symptoms or signs within 5–10 days after
initial improvement (double-sickening)

Organism Adult children

S. pneumoniae 38 21-33
H. influenzae 36 31-32
M. catarrhalis 16 8-11

Sinusitis from M.catarrhalis can spontaneously resolve about 70%

 Treatment of acute sinusitis

Indication IDSA 2012 AAP 2013 Thai guideline

1st line regimen Amoxicillin-clav 45 MKDay Amoxicillin 45 MKDay Amoxicillin 45-50 MKDay
Alternative Amoxicillin-clav 90 MKDay Amoxicillin-clav 90 MKDay Amoxicillin 90 MKday (if
regimen suspect DRSP)
B-lactam allergy Cefuroxime or cefprozil or
- Type I • Levofloxacin 10-20 MKDay • Levofloxacin 10-20 Macrolide or
- Non type I • Clindamycin 30-40 MKDay MKDay Bactrim
plus Cefixime 8 MKDay • Clindamycin 30-40
MKDay plus Cefixime 8
MKDay
- For treatment • Amoxicillin-clav 90 MKDay • Amoxicillin-clav 90 MKDay Amoxicillin 80-90 Mkday or
failure • Levofloxacin 10-20 MKDay Cefuroxime or
- Risk for ATB • Clindamycin 30-40 MKDay cefprozil
resistance plus Cefixime 8 MKDay
Duration of treatment : 14 days
Treatment of acute sinusitis
AAP guideline 2013
*.amuion 72 hr.
Treatment option Failure at 72 hr Clinical not improve within 72 hr

Clinical observation Amoxicillin with/without clav Further observation or start

Amoxicillin 40 MKDay Amoxicillin 80-90 MKDay
Amoxicillin-calv 80-90 MKDay Clindamycin plus cefixime
Or
Levofloxacin
amoxicillin
Con’t amoxicillin or switch to
amoxicillin-clav 80-90 MKDay
Con’t amoxicillin-clav or switch
to clindamycin plus cefixime
Or
levofloxacin
ACUTE OTITIS MEDIA
S.pneumoniae, H. influenzae, M. catarrhalis
 Acute otitis media : AAP guideline 2013

Age Otorhea with Unilat or bilat AOM Bilat Aom without Unilat AOM without
With severe symptom otorrhea otorrhea
6 mo-2 yr ATB therapy ATB therapy ATB therapy ATB therapy or
now it additional
observation
≥2 yr ATB therapy ATB therapy ATB therapy or ATB therapy or
additional additional
(0524 observation observation
Additional observation : 48-72 hours
Acute otitis media : AAP guideline 2013

Intial immediate or delayed ATB treatment ATB treatment after 48-72 hr of failure of intial ATB
treatment
Recommended 1st line Alternative treatment Recommended 1st line Alternative treatment
(if penicillin allergy)
• Amoxicillin 80-90 • Cefdinir 14 MkDay • Amoxicillin-clav 90 • Ceftriaxone plus 3 d
MkDay Or MkDay clindamycin 30-40
Or • Cefuroxime 30 Mkday Or MkDay
• Amoxicillin-clav 90 Or • Ceftriaxone 50 MkDay • Tympanocentesis
MkDay • Ceftriaxone 50 MkDay IM or IV • Consult specialist
IM or IV
Duration of treatment : 7-10 days
 7-10 day
Acute otitis media : Thai guideline
Situation Regimen
Initial treatment
- No risk for DRSP Amoxicillin 40-50 MkDay
- Risk for DRSP Amoxicillin 80-90 MkDay
If conjunctivitis Amoxicillin-clav 90 MkDay
Type I penicillin allergy Azithromycin 10 MkDay x1 day then 5 MkDays x 4 days or
Clarithromycin 15 MkDay
Non type I penicillin Cefdinir 14 MkDay or
allergy Cefditoren 9-18 MkDay or
Cefuroxime 30 MkDay or
Failure after 48-72 hours
Amoxicillin-clav 80-90 MkDay or
Cefdinir 14 MkDay or
Cefdditoren 9-18 MkDay or
Ceftriaxone 50 MkDay IM or IV or
 (omrios)
GROUP A STREPTOCOCCAL
PHARYNGITIS
L Modaserial ansanowr
diw
viral sinusitis
=
 Drug Dose or dosage Duratio recommendation,
n strength, quality
Penicillin V Children: 250 mg bid-tid 10 days Strong, high
Adolescents & adult: 250 mg qid or
500mg bid sinusitis
rotitis,
Amoxicillin 50 mg/kg OD-bid (max 1000 mg)
mmun
10 days Strong, high
Benzathine penicillin G <27 kg : 600,000 U 1 dose Strong, high
≥27 kg : 1,200,000 U
For penicillin allergy
Cephalexin 20 mg/kg/dose bid (max 500 10 days Strong, high
mg/dose)
Cefadroxil 30 mg/kg OD (max 1 gm) 10 days Strong, high
Clindamycin 7 mg/kg/dose tid (max 300 mg/dose) 10 days Strong, moderate
Azithromycin 12 mg/kg/dose OD (max 500 mg) 5 days Strong, moderate
Clarithromycin 7.5 mg/kg/dose bid (max 250 10 days Strong, moderate
mg/dose)
D A
Treatment within 9 days of the onset of illness is effective in preventing acute rheumatic fever (ARF).
However, treatment of pharyngitis does not affect the development of APSGN
X
COMMUNITY ACQUIRED
PNEUMONIA
 Basic knowledge of childhood pneumonia

Neonate Infant Children <5 yr Children >5 yr

Virus HSV CMV RSV Respiratory viruses
Enteroviruses RSV Influenza EBV
Adenovirus Parainfluenza Parainfluenza mumps
Mumps Influenza Adenovirus
CMV Adenovirus Human metapneumovirus
Metapnuemovirus Rhinovirus

Bacteria Gr. B streptococci H. influenzae S. pneumoniae S. pneumoniae

Gr. negative bacteria S. pneumoniae H. influenzae M. pneumoniae
L. monocytogenes C. trachomatis S. aureus C. pneumoniae
U. urealyticum
Site of care Empiric therapy
Presumed bacterial Presumed atypical Presumed influenza
pneumonia Step. Prem pneumonia pneumonia
Outpatient
<5 years old Amoxicillin 90 MkDay Azithromycin 10 Oseltamivir
(preschool) Mkday on day 1 then 5
Alternative MkDay on day 2-5
Amoxicillin-clav 90 Mkday
Alternative
Clarithromycin 15
MkDay 7-14 days or
erythromycin
≥5 years old Amoxicillin 90 MkDay Azithromycin 10 Oseltamivir
For children with Mkday on day 1 then 5
presumed bacterial CAP MkDay on day 2-5
who do not have clinical,
lab or X-ray evidence that Alternative
distinguishes bacterial Clarithromycin 15
from CAP, macrolide can MkDay 7-14 days or
be added to B-lactam erythromycin or
doxycycline
Site of care Empiric therapy
Presumed bacterial Presumed atypical Presumed influenza
pneumonia pneumonia pneumonia
Inpatient
rid vaccine Nor

Fully immunized with Ampicillin or penicillin G Azithromycin 10 Mkday on Oseltamivir

conjugate vaccines for day 1 then 5 MkDay on
Hib and S.pneumoniae Alternative : day 2-5
Ceftriaxone or cefotaxime
Local penicillin Alternative
resistance is minimal Clarithromycin 15 MkDay
7-14 days or erythromycin
-
Not fully immunized Ceftriaxone or cefotaxime ⑦ Azithromycin 10 Mkday on⑰Oseltamivir
for Hib and S. day 1 then 5 MkDay on
pneumoniae Alternative day 2-5
Levofloxacin
Local penicillin Alternative
resistance is Clarithromycin 15 MkDay
significant. 7-14 days or erythromycin
or doxycycline or
Levofloxacin
BACTERIAL MENINGITIS
Bacterial meningitis 3rd gen cet. Gard

Predisposing factor Common bacterial pathogens ATB therapy

<1 mo GBS, E.coli, L.monocytogenes, • Ampicillin plus cefotaxime or
Kiebsella species • Ampicillin plus aminoglycoside
1-23 mo S.pneumoniae, N.meningitidis, GBS, • 3rd generation cephalosporin
H.influenzae, E.coli
2-50 yr N.meningitidis, S. pneumoniae • 3rd generation cephalosporin
Head trauma
Basilar skull fracture S.pneumoniae, H. influenzae, GAS • 3rd generation cephalosporin
Penetrating trauma S.Aureus, CONS, gram neg bacilli • Vancomycin plus ceftazidime
including P.aeruginosa
Post neurosurgery Gram neg bacilli including • Vancomycin plus ceftazidime
P.aeruginosa, S.aureus, CONS
CSF shunt CONS, S.aureus, gram neg bacilli • Vancomycin puls ceftazidime
(including P.aeruginosa),
propionibacterium acnes
Pneumococcal meningitis

■ Regimen : cefotaxime/ceftriaxone +/- vancomycin

■ Bacterial meningitis possibly or proven to be caused by S.
pneumoniae
– EIA positive for S. pneumoniae

B
Case Streppnerno.
– Gram stain : gram positive diplococci

Combination therapy with

3rd gen cephalosporin + vancomycin
should be used.
# Rifampicin *
CLSI Definitions of In Vitro Susceptibility and
Nonsusceptibility of Nonmeningeal and Meningeal
Pneumococcal Isolates

Drug and Isolate Susceptible, ug/ml Non susceptible, ug/ml

Location Intermediate Resistance
Penicillin (oral) ≤ 0.06 0.12-1.0 ≥ 2.0
Penicillin (IV)
- Nonmeningeal ≤ 2.0 4.0 ≥ 8.0
- Meningeal ≤ 0.06 None ≥ 0.12
Cefotaxime or cef-3
- Nonmeningeal ≤ 1.0 2.0 ≥ 4.0
- Meningeal ≤ 0.5 1.0 ≥ 2.0
CLSI Definitions of In Vitro Susceptibility
and Nonsusceptibility of Nonmeningeal and
Meningeal Pneumococcal Isolates
Susceptibility test results
Susceptible to penicillin
Nonsusceptible to penicillin and Susceptible
to cefotaxime and ceftriaxone
Nonsuscepible to penicillin and cefotaxime
and ceftriaxone and susceptible to rifampicin
Antimicrobial management
Discontinue vancomycin and
Begin penicillin (discontinue cephalosporin)
OR
Continue cefotaxime or ceftriaxone alone
Discontinue vacomycin and
Continue cefotaxime or ceftriaxone
Continue vancomycin and high dose
cefotaxime or ceftriaxone and rifampicin may
be added in some circumstance.
FEBRILE URINARY
TRACT INFECTION
Febrile urinary tract infection in children
Parenteral ATB Dosage Oral ATB Dosage
Ceftriaxone 75 mg/kg q every 24 hr Amoxicillin-clav** 20-40 mg/kg/day tid
Cefotaxime 150 mg/kg/day q 6-8 hr Bactrim 6-12 mg/kg of trimethoprim
Ceftazidime 100-150 mg/kg/day q 8 hr Cefixime** 8 mg/kg/day OD
Gentamicin 7.5 mg/kg/day q 24 hr Cefpodoxime 10 mg/kg/day bid
Tobramycin 5 mg/kg/day q 8 hr Cefprozil 30 mg/kg/day bid
Piperacillin/tazobactam 300 mg/kg/day q 6-8 hr Cefuroxime axetil 20-30 mg/kg/day bid
Cephalexin 50-100 mg/kg/day qid

When initiating treatment, the clinician should base the choice of route of administration on
practical considerations. Initiating treatment orally or parenterally is equally efficacious.
The clinician should choose 7 to 14 days as the duration of antimicrobial therapy.
(evidence quality: B; recommendation)
BM Positive: did Enterococci - T: Ampicillin
INFECTIOUS DIARRHEA
 Empirical ATB Therapy in Acute Diarrhea
widon: 1. <30
Indication for Antibiotic 2 .Immono com

– Cholera spp., shigella 3. Main Shigella; samondi sown

– Consider in those without clue of viral

infection
■ Severe or Persistent
Choices
■ Dysentery
Norfloxacin (or ciprofloxacin)
■ Age < 6 months 3rd gen cephalosporin
■ Immunocompromised/ Underlying disease - cefixime
TMP/SMX (not proven effective)
Antibiotics are indicated for salmonella gastroenteritis only in..
– Neonate younger than 3 mo
– Immunocompromised host and HIV infected patients
– Hemoglobinopathy ex. Thallassemia, sickle cell anemia
Inappropriate Use of ATB in Diarrhea

■ Not shorten illness

■ Unnecessary cost
■ Risk for A/E
■ Prolong shedding (Salmonella)
■ Increase Risk of HUS (STEC)
■ Create drug resistance problem

More than 80% of acute diarrhea are from viral / or self-limited

SEPTIC ARTHRITIS
Childhood septic arthritis Picose to inpati
Risk groups Organism :siroger
Antibiotic
Neonate Gr.B streptococci, S.aureus,E.Coli, Other cefotaxime
enteric gram negative bacteria
Children < 5 yr
Cartones fromO
S. aureus, kingella kingae, S. pyogenes,
S. pneumoniae, H. influenzae type B
Ocefotaxime or ceftriaxone
·
rial judgen
Children > 5 yr S. aureus, S. pyogenas cloxacillin, dicloxacillin or
Com O cefazolin -
History of IVDU P. aeruginosa Ceftazidime ±
aminoglycoside
Sickle cell anemia Salmonella spp. Cefotaxine or ceftriaxone
History of sexual N. gonorrhea ceftriaxone
activity

Salmonella should be suspected in children aged younger than 1 year old.

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