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)
Influenza Children with risk factors should be treated with antivirals (as per PHE guidance) if admitted to hospital with confirmed or presumed influenza infection (during periods that influenza is known to be circulating locally). Only treat children without risk factors who are admitted to PHDU / PICU with confirmed or presumed influenza infection. For Oseltamivir (the choice of antiviral agent in severely immunocompromised patients depends on the predominant circulating strain ie H3N2 versus H1N1 (higher risk of oseltamivir resistance with H1N1). Where indicated, treatment should be initiated as soon as possible (ideally within the first 48 hours of symptoms). 5 days Ventilator associated pneumonia (for patients on NICU, see neonatal section) Community acquired organisms most likely if early-onset VAP (See above) Enterobacter cloacae, Pseudomonas aeruginosa, Acinetobacter species, Stenotrophomonas maltophilia Staph. aureus (including MRSA) If <5 days since admission, ceftriaxone IV. If already on ceftriaxone at the time of respiratory deterioration, switch to piperacillin/tazobactam IV. If >5 days since admission, piperacillin/tazobactam IV. Review with BAL results. If confirmed VAP, 5-7 days. If non-lactose fermenting Gram -ve (Pseudomonas spp., Acinetobacter), minimum 10 day course. If VAP unlikely, stop Abs after 48 hours. Pleural empyema Strep. pneumoniae Staph. aureus Non-typeable H. influenzae Ceftriaxone IV. Add clindamycin if any evidence of toxin mediated disease (haemodynamic instability, mucosal erythema, rash, diarrhoea etc). Usually 2 weeks minimum. Consider IV to oral switch (co-amoxiclav) once fever resolving and CRP normalising. [azithromycin PO if penicillin allergy]
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]
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]
CARDIOVASCULAR INFECTION Most likely causal organisms First choice Ongoing management / MINIMUM duration of antibiotic therapy Infective endocarditis Strep. viridans Staph. aureus Enterococci Coagulase negative staphylococcus Benzylpenicillin IV and gentamicin IV (gentamicin as per endocarditis dosing regimen – 2.5mg/kg 8 hourly if >1 month of age). If suspected Staph. aureus or septic shock, flucloxacillin IV and gentamicin IV (gentamicin as per endocarditis dosing regimen – 2.5mg/kg 8 hourly if >1 month of age) If prosthetic material in situ, likely coagulase negative staphylococci or MRSA, or penicillin allergy, use vancomycin IV, rifampicin (IV initially) and gentamicin IV. Duration depends on organism. Discuss with infection team. Stop gentamicin after 7 days. Send minimum 3 blood cultures prior to commencing antibiotics For persistent positive blood culture despite appropriate antibiotics, discuss with microbiology/ID team. Children on ECMO Staph. aureus Coagulase negative staphylococcus Gram negative organisms including E coli, Klebsiella and Pseudomonas spp. Neck cannulation without open chest: stat dose of vancomycin IV and gentamicin IV at the time of cannulation and decannulation. Open chest cannulation: vancomycin IV and gentamicin IV for 48 – 72 hrs (depending on ongoing need for recurrent chest re-exploration). Further stat dose of vancomycin IV and gentamicin IV prior to decannulation if off Abs. Deterioration on ECMO: vancomycin IV, gentamicin IV and piperacillin/tazobactam IV. Monitor renal function and antibiotic levels.
Sternal wound infections post cardiothoracic surgery Staph. aureus Flucloxacillin IV. Consider debridement, vacuum-assisted closure. [Clindamycin if penicillin allergy] If no improvement, consider switch to vancomycin IV Vancomycin IV empirically if known MRSA colonised. If no debridement required, 2 weeks. If debridement, for 4 weeks. Consider IV to oral switch: cefalexin co-amoxiclav flucloxacillin [Clarithromycin if penicillin allergy] Necrotising enterocolitis or typhlitis Gram negative organisms such as E. coli and Klebsiella. Enterococcus Pseudomonas spp. Anaerobes Amoxicillin IV, gentamicin IV and metronidazole IV. If central line in situ, consider vancomycin IV, gentamicin IV and metronidazole IV (teicoplanin used empirically in Portsmouth and HHFT). If overwhelming sepsis or bowel perforation, consider piperacillin/tazobactam, gentamicin IV and metronidazole IV (+- vancomycin IV if central line in situ). If CNS infection likely, use meropenem instead of piperacillin/tazobactam and metronidazole. 7-10 days (longer duration if lack of clinical improvement) Discontinue Abs after 2-3 days if NEC thought unlikely
ENT INFECTION Most likely causal organisms First choice Ongoing management / MINIMUM duration of antibiotic therapy Tonsillitis Most young children presenting with tonsillitis have a viral aetiology. Group A streptococcus Consider testing for EBV (EBV serology) Base decision to treat on ( 1 point for each of Fever, Purulence, Attend within 3 days of onset or less, severely Inflamed tonsils, No cough or coryza): score 0-1 = 18% streptococci: use NO antibiotics score 2-3: 34-40% streptococci, use back up/delayed antibiotic score ≥4: 62-65% streptococci, use immediate Ab. Based on Score validated in children 3 years and over – younger children are less likely to have a bacterial aetiology and are less likely to develop complications. No significant difference in pain score at day 3 in children treated with antibiotics compared to those treated with placebo (). Need to treat >4000 children with antibiotics to prevent one case of quinsy. Most children with tonsillitis do not require a throat swab. For children unable to swallow tablets; amoxicillin 40mg/kg bd PO (max 1g per dose) for 7 days (2012 ). The use of amoxicillin does not significantly increase the risk For children able to swallow tablets; if age 6-12 years, penicillin V 500mg bd; if age >12 years, penicillin V 1 g bd for 7 days (see ). [azithromycin PO for 5 days for penicillin allergy] If unable to tolerate oral antibiotics, ceftriaxone IV (clindamycin if severe penicillin allergy). 7 days Provide safety netting information (verbal and written) when a watchful waiting approach is taken and when antibiotics are prescribed. Consider a delayed prescribing approach. Consider oral switch to amoxicillin If confirmed EBV, stop Abs Peritonsillar abscess (quinsy) Group A streptococcus Anaerobes Ceftriaxone IV + metronidazole IV / PO 10 days Consider oral switch to co-amoxiclav
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
>28 days-18yr: 60mg/kg IV 8-hourly (max dose 1g every 8 hours) Enterococcal endocarditis: <7days: 60mg/kg 12-hourly 7- 28days: 60mg/kg 8-hourly. >28 days-18yr: 60mg/kg 4–6 hourly (max 2g 4- hourly). Amphotericin (Ambisome®) Treatment: All ages: test dose 100micrograms/kg (max 1mg) over 15mins, observe for 30mins. If no reaction follow 1 hr later by 3mg/kg once daily Prophylaxis: 1mg/kg once daily on Mon, Wed, Fri
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