Ventriculoperitoneal shunt infection Coagulase negative staphylococcus Staph. aureus Vancomycin IV and ceftriaxone (cefotaxime IV in children age <1 month if jaundiced or gestational age <37 weeks) Shunt removal required (CoNS infection may be treated conservatively – remove shunt if CSF not sterilised) If ventriculitis strongly suspected, add intrathecal vancomycin (should be used in conjunction to IV vancomycin) Discuss all suspected cases with UHS neurosurgeons and local microbiologists. Uncomplicated 10 days Complicated 21 days (ventriculitis, severe peritonitis, remaining prosthetic material)
SKIN AND SOFT TISSUE INFECTION Most likely causal organisms First choice [acceptable alternative] Ongoing management / MINIMUM duration of antibiotic therapy Cellulitis Staph. aureus Group A streptococcus Group G streptococcus Consider α-haemolytic streptococci or anaerobes if facial cellulitis If recurrent or severe Staph aureus infection, consider PVL testing. If mild/moderate infection, oral cefalexin or oral co- amoxiclav. [Clarithromycin if confirmed penicillin allergy] If severe infection:- ceftriaxone IV [if severe penicillin allergy, use clindamycin] Add metronidazole if facial cellulitis (see ophthalmology section for periorbital cellulitis) Add clindamycin if associated sepsis / signs of toxin mediated disease (risk factors include chickenpox or burns). Consider IVIG 2g/kg. 7 days (may have oral switch) Consider ambulation and daily review on ceftriaxone IV (+- metronidazole po) Oral Cefalexin or co-amoxiclav or [Clarithromycin if penicillin allergy] or co-amoxiclav for facial cellulitis Provide safety netting information (verbal and written) prior to discharge. Impetigo Staph. aureus Group A streptococcus If mild/moderate infection, use oral cefalexin or co- amoxiclav [clarithromycin if confirmed penicillin allergy] If severe infection, use ceftriaxone IV [if severe penicillin allergy, use clindamycin] Optimisation of topical steroids is the mainstay of treatment in these patients. 5 days (may have oral switch) Oral options – cefalexin or co-amoxiclav or [clarithromycin if penicillin allergy]
Bites (not insect bites) Staph. aureus Bacteroides spp. Pasteurella multocida Group A streptococcus (human bites) Often polymicrobial (aerobic + anaerobic) Antibiotics are not generally needed if the wound is more than 2 days old and there is no sign of local or systemic infection Prescribe antibiotics for: All human bite wounds under 72 hours old. All cat bites, animal bites to the hand, foot, and face; puncture wounds; wounds requiring surgical debridement; wounds involving joints, tendons, ligaments, or suspected fractures. Wounds that have undergone primary closure. Children who are at risk of serious wound infection (for example those who are asplenic, or immunosuppressed). Children with a prosthetic valve or a prosthetic joint. If mild/moderate injury, for oral co-amoxiclav. If severe or deep penetrating, IV co-amoxiclav and clindamycin po/IV [Azithromycin and metronidazole if penicillin allergy] 7 days if mild penetrating injury. 14 days if severe or deep penetrating injury – IV antibiotics followed by oral co- amoxiclav. Consider tetanus and hepatitis B vaccine if human bite. Consider tetanus immunoglobulin if animal bite in children with incomplete tetanus immunisation status. Secondary infections following burns Staph. aureus Group A streptococcus Pseudomonas aeruginosa Candida spp. Do not use topical prophylactic Abs post-burns If mild/moderate infection, use oral cefalexin or co- amoxiclav [clarithromycin if confirmed penicillin allergy] If severe infection, use ceftriaxone If know colonised with pseudomonas, for piperacillin/tacobactam (tazocin) If signs of systemic upset and /or diarrhoea and/or spreading rash, treat as toxic shock syndrome and add IV clindamycin. Consider IVIG 2g/kg (preferable to FFP as higher antitoxin concentration) 7 days (may have oral switch) Consider ambulation and daily review on ceftriaxone IV Oral cefalexin or co-amoxiclav or [clarithromycin if penicillin allergy]
BONE AND JOINT INFECTIONS INFECTION Most likely causal organisms First choice Ongoing management / MINIMUM duration of antibiotic therapy Osteomyelitis or septic arthritis Staph. aureus Strep. pneumoniae Group A streptococcus H. influenzae Kingella kingae Consider TB Salmonella in Sickle cell < 1 month of age treat with cefotaxime IV. Consider ceftriaxone if ≥37 weeks gestation and not jaundiced. Children under 1 month of age with serious bacterial infection require a LP unless contraindicated. >1month- 5 years ceftriaxone IV. >=6 years flucloxacillin 50 mg/kg/qds IV (maximum 2g/dose) (clindamycin IV if penicillin allergy) Duration guided by clinical signs and CRP. Usual: 4-6 wks Septic arthritis: 2-3 wks Consider IV to oral switch when improvement in pain, resolution of fever and CRP<20mg/L or <1/3 of highest CRP Oral options include cefalexin or co-amoxiclav or [clarithromycin if penicillin allergy]
CYSTIC FIBROSIS SPECIALITY GUIDELINES Assess previous sputum microbiology results (organisms isolated and their sensitivities) Patient group Most likely causal organisms First choice No previous Pseudomonas aeruginosa Must cover common pathogens including: Staph. aureus H. influenzae Moraxella catarrhalis As well as possible first isolate (especially young infants) of: Pseudomonas aeruginosa Cefuroxime IV + tobramycin IV See below if Pseudomonas aeruginosa isolated. Previous or proven current infection with Pseudomonas aeruginosa Pseudomonas aeruginosa H. influenzae Moraxella catarrhalis Ceftazidime IV + tobramycin IV (unless previous sensitivities suggest otherwise) Staph. aureus isolated within previous 12 months and patient NOT on long-term azithromycin (or Staph. aureus reported erythromycin-resistant) Ceftazidime IV + tobramycin IV + flucloxacillin PO
Cefalexin 1mo-18yr: 25mg/kg 8-hourly (max 1g per dose) Cefotaxime <7days: 50mg/kg 12-hourly 7-21days: 50mg/kg 8-hourly 21days-18yr: 50mg/kg 8-hourly (6 hourly for meningitis) (max. 12g per day) Neonatal dose banding option for >0.5kg babies with early-onset sepsis (if over 7 days of age change to 50mg/kg 8-hourly): Cefoxitin CF only: >1mo: 40mg/kg 6-hourly (max 3g/dose) Ceftazidime <7days: 50mg/kg 24-hourly 7-20days: 50mg/kg 12-hourly 21days–18yr: 50mg/kg 8-hourly (max. 6g daily except CF with pseudomonas chest infection when max 9g daily (if over 12yr up to 12g daily may be considered.) CF: (nebulised using iv prep) 1g 12-hourly Ceftriaxone Can use ceftriaxone age <1 month if ≥37 weeks gestation & no contraindications (see below) <15 days: 50 mg/kg once daily ≥15 days: 80mg/kg once daily (max 4g daily) 2nd dose of ceftriaxone can be given between 12-24 hours following the first dose to facilitate ambulation – .
Prevention of secondary case of meningococcal meningitis 0-11mo: 5mg/kg 12-hourly for 2 days. 1–18yr: 10mg/kg 12-hourly (max. 600mg/dose) for 2 days. Teicoplanin <1mo: 16 mg/kg loading dose, then 8 mg/kg once daily, starting 24 hours after loading dose. ≥1mo:10 mg/kg 12-hourly for 3 doses, then 10 mg/kg once daily (max400 mg/dose) Tobramycin For 8-hourly dosing monitor levels 2hr before and 1hr after the 2nd dose and again on day 8. For once daily dosing monitor trough levels 18 hr after 1st dose and repeat on day 8. Target trough <1mg/L 1mo-1yr: 3mg/kg 8-hourly >1 yr-18yr: 7mg/kg once daily for non-CF patients (inc. PCD patients) CF only: 1mo-1yr: 7mg/kg once daily >1yr:10mg/kg once daily (may be switched to 3.3mg/kg 8-hourly bolus dosing for home). CF (nebuliser solution not iv prep): 300mg 12- hourly (alternate months) Trimethoprim Prophylaxis: All ages: 2mg/kg once daily at night (max 100mg/dose) Treatment: <1mo: Initially 3mg/kg for 1 dose, then 2mg/kg 12- hourly >1mo: 4mg/kg 12-hourly (max 200mg/dose) Valaciclovir Treatment of herpes simplex or herpes zoster in immunocomprosed patients: 3mo - <12 yr: 20mg/kg 8-hourly (suspension will need to be made up specially in hospital pharmacy) ≥12yr: 1 gram 8-hourly