Pediatric antibiotics

Neonatal Infections

• All doses are for patients >2 kg and at least 7 days of age
• Always treat for meningitis until you are sure it is not

Neonatal (0-28 days)

• If <14 days, Ampicillin 50 mg/kg/dose AND (Gentamicin 4 mg/kg/dose or Cefepime 30mg/kg/dose)
• If >14 days, Ampicillin 50 mg/kg/dose AND Ceftriaxone^^ 50-100mg/kg/dose
• Acyclovir^ 20 mg/kg/dose

^Acyclovir if:

• HSV infection in baby or mother
• CSF pleocytoisis
• Concerning skin lesions
• Seizures
• Abnormal LFTs

Neonatal (28-90 days)

• Ampicillin 50 mg/kg/dose AND Ceftriaxone^^ 50-100mg/kg
• Acyclovir^ 20 mg/kg

^Acyclovir if:

• HSV infection in baby or mother
• CSF pleocytoisis
• Concerning skin lesions
• Seizures
• Abnormal LFTs

Meningitis

MRSA is uncommon in the neonate

• Ampicillin 75mg/kg IV q6hrs PLUS
• Cefotaxime 50mg/kg IV q6hrs OR Gentamicin 2.5mg/kg IV q8hrs
  • Per AAP, ceftazidime 50mg/kg IV (q12hr for babies < 8 days of age, q8hr for >7 days old) is a reasonable alternative to cefotaxime, offering virtually the same coverage for enteric bacilli and is FDA approved for all age groups
• If suspecting S. pneumoniae or MRSA, add Vancomycin
• Consider acyclovir for HSV

• Acyclovir 20 mg/kg IV every 8 hours (duration depends on classification)
• If ocular involvement:
  • 1% trifluridine, 0.1% iododeoxyuridine, or 3% vidarabine
  • Optho consult
• As for any febrile neonate SBI evaluation:
  • Ampicillin + gentamycin
    • May substitute gentamycin with cefotaxime/ceftazidime

Pneumonia (peds)

Newborn

• Hospitalized
  • Ampicillin (80-90mg/kg/day) + gentamicin +/- cefotaxime
    • Add vancomycin if MRSA a concern
    • Add erythromycin (12.g mg/kg QID) if concern for chlamydia
• Outpatient
  • Initial outpatient management not recommended

1-3 Month

• Hospitalized
  • Afebrile pneumonitis
    • Erythromycin (10 mg/kg q6) or Azithromycin (2.5 mg/kg q12)
  • Febrile pneumonia
    • Add Cefotaxime (200mg/kg per day divided q8h)
• Outpatient
  • Erythromycin OR Azithromycin PO

>3mo - 18 years

• Hospitalized (PICU/severely ill)
  • Ceftriaxone IV AND Vancomycin AND consider Azithromycin
• Hospitalized (moderately ill)
  • Fully immunized: Ampicillin (50mg/kg q6) IV
  • Not fully immunized: Ceftriaxone IV
• Outpatient
  • Amoxicillin (90 mg/kg divided BID) x 10 days PO
    • Some studies have shown that 5 day course may also be adequate treatment
  • Alternative: Clindamycin OR Azithromycin OR Amoxicillin-clavulanate

Osteomyelitis

• Empiric treatment: Nafcillin 200mg/kg/day IV div Q6 AND cefotaxime 150mg/kg/day IV div Q8 for >21 days.

UTI (peds)

• <2 weeks: Ampicillin 100mg/kg/day IV div Q6 (or Q12 if <7 days) AND gentamicin 3mg/kg/day IV Q24 OR cefotaxime 150mg/kg/day IV div Q8
• 2 weeks - 2 months: Ampicillin 100mg/kg/day IV div Q6 AND cefotaxime 150mg/kg/day div Q8

Neonatal conjunctivitis

Prophylaxis

• Erythromycin 0.5% ointment x1 or tetracycline 1% or silver nitrate 1% x1 topical (rarely used because of its potential for causing chemical conjunctivitis), applied at birth.

Chemical

• Watchful waiting

Gonococcal (onset 2-4 days)

• Cefotaxime 100mg/kg IV or IM OR ceftriaxone 25-50mg/kg IV or IM x1 (not to exceed 125mg)
  • Cefotaxime is preferred because it does not displace bilirubin
  • Disseminated disease should be suspected until CSF is negative
  • Treat mother and partners
  • Irrigate eyes with saline (topical antibiotics are insufficient and unnecessary)

Chlamydia (onset 5-10 days)

• Erythromycin ophthalmic ointment plus one of the following
  • Azithromycin 20mg/kg PO once daily x 3 days OR
  • Erythromycin 50mg/kg PO QD in 4 divided doses x 14 days
• Disease manifests 5 days post-birth to 2 weeks (late onset)

Herpetic (onset 6-14 days)

• Acyclovir 20mg/kg IV q8hr x 14-21d
• Topical antiviral
• Do not give steroids
• Full neonatal sepsis evaluation
• Immediate ophtho consult

Febrile Syndromes/Bloodstream Infections

Pediatric fever of uncertain source (90 days - 36 months)

• Ceftriaxone (50-100mg/kg/dose) AND
• Consider vancomycin (15mg/kg)^^^^

Septic shock syndromes	Bacteremia: S. pneumo, N. meningitidis, H. influenzae (if not immunized)	Replete intravascular volume, maximize delivery of oxygen to tissues. Blood cultures. Ceftriaxone 50mg/kg/day IV/IM Q24 or Cefotaxime 150mg/kg/day IV div Q8 until afebrile x24 hours.
	Toxic shock syndrome: Staphylococcal (less often associated with deep tissue disease), Streptococcal	Empiric therapy should include clindamycin and beta-lactam until etiology is isolated. Staphylococcal: Most often associated with toxin-producing organism at a mucosal site, may involved disease at a deeper site. Associated with tampon use, wound infection or burns. 5-15% case fatality rate. Rx: Nafcillin AND clindamycin initially. Substitute cefazolin or vancomycin for nafcillin if MRSA suspected. IVIG 1 g/kg may bind toxins, but should be reserved for life-threatening infections. Streptococcal: Invasive disease at a deep site is the rule; deep site infection should be sought aggressively and treated. Defined as isolation of GAS, hypotension, renal impairment, coagulopathy, ARDS and soft tissue necrosis. Associated with erysipelas, Necrotizing Fascitis, secondary infection of varicella. Rx: Once streptococcus is identified, change therapy to penicillin or other ß-lactam antibiotic PLUS Clindamycin.
Central line infection	Coagulase-negative Staph (CONS), S. aureus, GN-bacilli, Candida spp.	Coagulase-negative Staph (CONS): can try to salvage catheter with 10-14 days of therapy (vancomycin), 80% cure rate for exit site infections, 25% if deeper. If S. aureus, Gram-Negative bacilli or Candida: always remove the catheter if possible. S. aureus has a 10% exit site cure rate and 0% deeper infection cure rate if catheter left in. If septic thrombophlebitis, endocarditis, osteomyelitis or repeated positive cultures, ALWAYS remove catheter.
	TPN/Intralipids: as above and Malassezia furfur	Remove catheter and discontinue antimicrobials if possible. If Candida albicans, treat with Fluconazole 6-12mg/kg/day IV Q24 (if >14 days old) x 28 days OR conventional Amphotericin B 1mg/kg/day IV div Q24. If Staph epidermidis, treat with vancomycin and discontinue intralipids. If M. furfur, treat with conventional Amphotericin B.
Fever and Neutropenia	Aerobic GNR, Strep viridans, MRSA	Piperacillin-tazobactam 400mg/kg/day IV div Q6 OR Ceftzidime 150mg/kg/day IV div Q8 OR Meropenem 60mg/kg/day IV div Q8. Consider adding gentamicin if persistently ill-appearing. Consider adding vancomycin if MRSA or coagulase-negative Staph suspected. Consider adding amphotericin B 1mg/kg/day IV Q24 if persistently febrile >5 days on antibiotics. Consider meropenem alone or addition of metronidazole if typhlitis suspected.
Lyme Disease	Borrelia burgdorferi	Early rash (erythema migrans), carditic, facial nerve palsy, meningitis/encephalitis, arthritis. Early localized/disseminated disease: doxycycline 4mg/kg/day PO div BID (if >7 yo) OR amoxicillin 50mg/kg/day PO (max 1.5 g/day) div TID x14-21 days. Alternative erythromycin 30mg/kg/day IV div Q8. Arthritis (no CNS disease): As above x28 days. Bell's Palsy: As above x21-28 days. Neuroborreliosis (CNS): ceftriaxone 75-100mg/kg/day IV Q24 OR penicillin G 300,000 U/kg/day IV div Q4 x14-21 days.
Rocky Mountain Spotted Fever	Rickettsia ricketsii	Suspect if fever, rash (95%), petechiae spreading from distal to central. Confirm with antibody titers. Ticks most often in Mid-Atlantic states. Treat empirically and aggressively, can be fatal. Doxycycline 4mg/kg/day PO div BID x7-10 days (recommend for all age groups).
Ehrlichiosis	Ehrlichia chaffensis or phagocytophilum	Suspect if febrile, flu-like illness with rash in April-Sept. Leukopenia and thrombocytopenia common. 80% have positive blood smear (HGE only). Dx HME with PCR. Confirm with DFA. Commonly co-infected with B. burgdorferi. Doxycycline 4mg/kg/day PO div BID x7 days.

CNS Infections

Meningitis (peds)

Treatment guidelines based on van de Beek et al

Neonates (up to 1 month of age)

MRSA is uncommon in the neonate

• Ampicillin 75mg/kg IV q6hrs PLUS
• Cefotaxime 50mg/kg IV q6hrs OR Gentamicin 2.5mg/kg IV q8hrs
  • Per AAP, ceftazidime 50mg/kg IV (q12hr for babies < 8 days of age, q8hr for >7 days old) is a reasonable alternative to cefotaxime, offering virtually the same coverage for enteric bacilli and is FDA approved for all age groups
• If suspecting S. pneumoniae or MRSA, add Vancomycin
• Consider acyclovir for HSV

> 1 month old

• Ceftriaxone 2gm (50mg/kg) IV BID daily PLUS
• Vancomycin 15-20 mg/kg IV BID daily
  • Vancomycin is for resistant Pneumococcus

VP shunt infections

• Empiric therapy: Vancomycin AND Cefotaxime 200 mg/kg/day IV div Q6 OR ceftriaxone 100 mg/kg/day IV div Q12-24
• Always involved neurosurgery in management
• Tailor antimicrobial therapy to culture results

Head, Eyes, Ears, Nose & Throat Infections

Mastoiditis, acute

S. pneumo (22%), S. pyogenes (16%), S. aureus (7%), H. flu, P. aeruginosa R/O meningitis. Surgical debridement as indicated. Transition to PO once clinically improved. Ampicillin-sulbactam 300mg/kg/dau IV div Q6 OR cefotaxime 150mg/kg/day div Q8 OR ceftriaxone 50mg/kg/day Q24 +/- nafcillin 200mg/kg/day IV div Q6 OR clindamycin 40mg/kg/day IV div Q6 or vancomycin x21 days.

Sinusitis, acute

1. Amoxicillin 90mg/kg/day x14-21 days.
   
2. Augmentin, cefuroxime or cefdinir if recent antibiotics or chronic sinusitis.

Conjunctivitis

• Adenovirus (types 3, 7)
  • AKA pink eye. No treatment needed. Highly contagious. Cold artificial tears may help. NEVER treat with steroids except by an ophthalmologist!
• HSV types 1-2
  • Can be sight-threatening. Refer to ophthalmologist immediately! 30-50% recurrence in 2 years.
  • Trifluridine OR idoxuridine ophthalmic solution 1 drop Q2-3 while awake x7-14 days.
  • Vidarbine ophthalmic ointment Q3 until 1 weeks after healthing.
• S. pneumo, H. flu
  • Polymyxin/trimethoprim ophthalmic solution 1 drop Q3 OR polymixin.bacitracin/Neosporin ophthalmic solution 1 drop Q3 x7-10 days.

Dacryocystitis

• Warm compresses and tear duct massage. No antimicrobial therapy usually needed. Oral antimicrobial therapy for more symptomatic infections

Orbital Cellulitis

• Ampicillin-sulbactam 300mg/kg/day IV div Q6 OR cefotaxime 150mg/kg/day div Q8 OR ceftriaxone 50mg/kg/day Q24 AND nafcillin 200mg/kg/day IV div Q6. If any MRSA isolated locally, add clindamycin 40mg/kg/day IV div Q6 OR vancomycin x10-14 days.

Periorbital (preseptal) Cellulitis

1. If known entry site: nafcillin 200mg/kg/day IV div Q6 OR cefazolin 100mg/kg/day IV Q8 x7-10 days. If MRSA suspected, Vancomycin OR clindamycin 40mg/kg/day IV div Q6. Oral antistaphylococcal antibiotics for less severe infections.
2. Periorbital swelling without cellulitis (often associated with sinusitis): Ceftriaxone 50mg/kg/day IV Q24 OR cefotaxime 150mg/kg/day IV div Q8. ADD clindamycin 40mg/kg/day IV div Q6 for more severe infections of suspicion of MRSA. See 'Head: Sinusitis' for oral therapy options.

Otitis Externa

• Clean canal often.
• Neomycin/Polymixin B +/- hydrocortisone otic drops. Alternate: Ofloxacin or ciprofloxacin solution. For 'swimmers ear' use VoSol (2% acetic acid) to canal.
• Candidal: Fluconazole 5-10mg/kg/day PO Q24 x5-7 days.

Otitis Media

Note: If >2 years, afebrile, no otalgia, borderline exam → consider symptomatic treatment or safety net antibiotic prescription (SNAP).

1. Amoxicillin 80-90mg/kg/day div BID or TID x10 days (<2 years) or x5 days (>2 years).
2. Augmentin 90mg/kg/day amoxicillin component div BID.
3. Cefdinir, cefpodoxime, cefprozil, cefuroxime. Azithromycin (up to 40% resistance in PRSP).

Ludwig's Angina

High risk of respiratory tract obstruction due to inflammatory edema.

1. Penicillin G 200,000 U/kg/day div Q6 AND clindamycin 40mg/kg/day IV vid Q6.
2. Consider

meropenem, piperacillin-tazobactam OR ceftriaxone if GNR suspected.

Dental abscess

1. Clindamycin 40mg/kg/day PO/IV/IM div Q6 or Penicillin G 100,000-200,000 U/kg/day IV div Q6.

Gingivostomatitis

• Acyclovir PO 80mg/kg/day div Q6 x7 days. For severe disease can use Acyclovir 30mg/kg/day IV div Q8.

Bacterial tracheitis

1. (Vancomycin OR clindamycin 40mg/kg/day div Q6) AND (Cefotaxime 150mg/kg/day div Q8 OR ceftriaxone 50mg/kg/day Q24). Tailor to cultures.
2. Cefuroxime 100-150mg/kg/day div Q8.

Epiglottitis

• Cefotaxime 150mg/kg/day div Q8 OR ceftriaxone 50mg/kg/day Q24. ADD Clindamycin 40mg/kg/day IV div Q6 OR vancomycin if Staph suspected.

Pharyngitis

• Throat: Culture before treating. GAS uncommon in children <3 years. Treatment decrease rheumatic fever 2.8 to 0.2%. Rx as below also for scarlet fever.

1. Penicillin V 25-50mg/kg/day PO div TID-QID OR amoxicillin 50-75mg/kg/day div BID-TID x10 days.
2. Penicillin G Benzathine 600,000 U IM (<27 kg), 1.2 million U (>27 kg) x1.
3. Erythromycin or clindamycin for PCN-allergic patients.

Respiratory Tract Infections

Pneumonia

Newborn

• Hospitalized
  • Ampicillin (80-90mg/kg/day) + gentamicin +/- cefotaxime
    • Add vancomycin if MRSA a concern
    • Add erythromycin (12.g mg/kg QID) if concern for chlamydia
• Outpatient
  • Initial outpatient management not recommended

1-3 Month

• Hospitalized
  • Afebrile pneumonitis
    • Erythromycin (10 mg/kg q6) or Azithromycin (2.5 mg/kg q12)
  • Febrile pneumonia
    • Add Cefotaxime (200mg/kg per day divided q8h)
• Outpatient
  • Erythromycin OR Azithromycin PO

>3mo - 18 years

• Hospitalized (PICU/severely ill)
  • Ceftriaxone IV AND Vancomycin AND consider Azithromycin
• Hospitalized (moderately ill)
  • Fully immunized: Ampicillin (50mg/kg q6) IV
  • Not fully immunized: Ceftriaxone IV
• Outpatient
  • Amoxicillin (90 mg/kg divided BID) x 10 days PO
    • Some studies have shown that 5 day course may also be adequate treatment
  • Alternative: Clindamycin OR Azithromycin OR Amoxicillin-clavulanate

Whooping cough

1. Erythromycin ethyl succinate 40mg/kg/day PO div QID x14 days (max 2000mg/day). Note: Do not use erythromycin base, which causes excessive GI symptoms.
2. Azithromycin (<6 months): 10mg/kg once daily x5 days (max 500mg). Note: Preferred agent for patients <1 month.

Cardiovascular Infections

Endocarditis

Prophylaxis indications Prosthetic cardiac valve or prosthetic material used for cardiac valve repair.

Previous infectious endocarditis.

Congenital heart disease (CHD) - except for the conditions listed below, antibiotic prophylaxis is no longer recommended for any other form of CHD.

• Unrepaired cyanotic CHD, including palliative shunts and conduits.
• Completely repaired CHD with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first 6 months after the procedure.
• Repaired CHD with residual defects at the site or adjacent to the site or a prosthetic patch or prosthetic device (which inhibit endothelialization).

Cardiac transplantation recipients who develop cardiac valvulopathy.

Prophylaxis for oral, dental, respiratory tract or high risk patients with chronic GI/GU infections

1. Amoxicillin 50mg/kg PO x1 OR Ampicillin 50mg/kg IV x1, 30-60 minutes prior to the procedure.
2. Allergic patients: Clindamycin 20mg/kg PO/IV x1 OR cephalexin 50mg/kg PO x1 OR azithromycin 15mg/kg PO x1.

Empiric therapy, native valves: S. viridans, Enterococci, Staphylococci

By definition includes multiple positive blood cultures, new murmur of valvular insufficiency, emboli and echo evidence of vegetations. Send cultures and target therapy based on results. Vancomycin and Gentamicin pending culture results.

Gastroenterologic Infections

Diarrhea	Initial Workup: If blood diarrhea or >6 stools/day and febrile then consider stool cultures, fecal leukocytes, electrolytes. Isolation: Contact precautions for diapered or incontinent children.
	C. difficile	Suspect if blood diarrhea, cramping develop with recent antibiotic exposure. Metronidazole 30mg/kg/day PO/IV div QID x10 days. Vancomycin 40mg/kg/day PO;div QID x10 days ONLY for Metronidazole failures.
	C. jejuni	Suspect if prominent abdominal pain. Young infants may only have bloody diarrhea. Can have immunoreactive complications such as AIDP, reactive arthritis, Reiter syndrome or erythema nodosum. Erythromycin 40mg/kg/day PO div QID x5 days. Shortens duration of illness and prevents relapse if given early.
	E. coli O157:H7 (Enterotoxin producing, ETEC)	Suspect if bloody diarrhea, >6 unformed stools/day and afebrile. Causes 36% of bloody diarrhea. Consider CBC and blood smear. If no hemolysis, azotemia or thrombocytopenia after 3 days of illness, risk of developing HUS is low. Antimicrobial therapy may precipitate an adverse reaction.
	Salmonella	May cause asymptomatic disease, gastroenteritis, bacteremia, osteomyelitis or meningitis. Exposures to lizards and other reptiles may result in unusual species of Salmonella. Antimicrobial therapy increases duration of illness in most carriers. Therapy recommended if invasive or focal disease, if <3 months old, chronic GI disease, oncology patients, hemoglobinopathies, or HIV+. May treat with amoxicillin or TMP-SMX; Ceftriaxone for neonates (not receiving calcium containing fluids) or septic clinical state.
	Shigella	Suspect if fever, cramps, tenesmus, abdominal pain. Complications include seizures, bacteremia, Reiter Syndrome, HUS (S. dystenteriae;type 1), toxic megacolon and toxic encephalopathy (ekiri syndrome). Cefixime 8mg/kg/day PO div BID or TMP-SMX 8mg/kg/day TMP PO div TID x5-7 days. Illness usually self-limited (48-72 hours), but treatment is always indicated to decrease duration of shedding, which is important for public health measures.
	Yersinia enterocolitica	Causes mesenteric adenitis, mimics appendicitis. Predisposed by iron overload states (chronic transfusions). Antimicrobial therapies not indicated in normal hosts.
Necrotizing Enterocolitis (NEC)	Multifactorial disease, including bacterial invasion (debated). E. coli, Klebsiella, Pseudomonas, Clostridial sp., S. aureus, B. fragilis.	Bacteremia in 30-50% of cases. Definitive antimicrobial therapy based on culture results. B. fragilis invades gut after several days of age. Ampicillin AND gentamicin x10 or more days Consider adding cefotaxime if CNS involvement cannot be excluded. Consider replacing ampicillin with vancomycin if MRSA/CONS. Consider adding clindamycin if perforation cannot be excluded.
Peritonitis (bowel perforation or appendicitis)	Enteric GNR, Bacteroides sp., Enterococcus sp.	Meropenem 60mg/kg/day IV div Q8 OR piperacillin-tazobactam 400mg/kg/day IV div Q6 x7-10 days. Ampicillin 150mg/kg/day IV div Q8 AND gentamicin (dose per age) IV div Q8 AND clindamycin 40mg/kg/day IV Q6 OR metronidazole 30mg/kg/day IV div Q6] x7-10 days.
Peritonitis (peritoneal dialysis)	Staphylococci, GNs, yeast	Antibiotic added to dialysate in concentrations approximating those attained in serum for systemic disease gentamicin 8mg/L, Vancomycin 50mg/L).

Genitourinary Infections

Pyelonephritis

Inpatient: Ceftriaxone 50mg/kg/day IV/IM Q24 OR gentamicin (age based dosing) OR [[TMP/SMX] 8mg/kg/day IV div BID x14 days. Treat IV until defervesces and clinically improved, then transition to PO.

Outpatient: TMP-SMX OR cefixime OR ciprofloxacin (in adolescents); see doses under UTI

UTI

Inpatient: >2 months: cefotaxime or ceftriaxone until taking PO, well appearing → transition to outpatient therapy.

Outpatient: (Infants and Children): TMP-SMX 6-10mg/kg/day TMP component div BID OR cefixime 16mg/kg/day x1 day, then 8mg/kg/day Q24 (max 400mg/dose) OR cephalexin 25mg/kg/dose QID (max 1000mg/dose) x7-14 days. Alternatives: nitrofurantoin, ciprofloxacin, ceftriaxone.

Skin & Soft Tissue Infections

Skin abscess

• OSSA/MSSA - Cephalexin 50-75mg/kg/day PO div TID OR Augmentin 80-90mg/kg/day PO div BID x5-7 days. I&D when indicated.
  
• If MRSA prevalent or if recurrent abscess, send specimen for culture and sensitivity. Treat with clindamycin 40mg/kg/day IV div Q6 or TMP-SMX 5mg/kg/dose TMP Q6-8. If toxic-appearing, use vancomycin.

Cellulitis

• Start IV: Clindamycin 40mg/kg/day IV div Q6 if high community incidence of MRSA. May use nafcillin 200mg/kg/day IV div Q6 OR cefazolin 100mg/kg/day IV div Q8 if low incidence of MRSA. Transition to PO when stable. If no improvement, change to vancomycin (dose by age).

• PO: Cephalexin 50-75mg/kg/day divided TID OR dicloxacillin 50mg/kg/day PO div Q6. Total duration of treatment 7-10 days.

Erysipelas

• Penicillin G IV, then transition to penicillin V or amoxicillin PO;x10 days.
  

Impetigo

• Mupirocin topical to lesions TID, cleanse with soap and water. Bathe daily. If extensive, treat with cephalexin PO or amoxicillin-clavulanate x5-7 days.

Omphalitis/Funisitis

• Empiric: Cefotaxime AND clindamycin x10 or more days.

• Funisitis (local infection of cord): cord care, topical antimicrobials.

Paronychia

• Local wound care and I&D unless signs of spreading infection, then consider Augmentin or clindamycin.

Scabies

1. Topical 5% permethrin cream, apply to neck down, wash off in 8-14 hours.
   
2. Topical Lindane 1%- Avoid unless treatment failure to permethrin due to risk of neurotoxicity. Many contraindications/precautions!

Staphylococcal scalded skin syndrome

1. Nafcillin 200mg/kg/day IV div Q6 OR Cefazolin IV x5-7 days. Consider vancomycin.

Avoid TMP-SMX.

Tinea corporis

• May use one of many topical antifungal agents: Terbinafine 1% cream or gel BID to affected areas; clotrimazole 1% cream, lotion or solution; others include Econazole, Sulconazole, Oxiconazole, Naftifine, Cicloprox, Ketoconazole, Sertaconazle, Moconazole and Tolnaftate. Treat for 14 days. Keep affected areas dry.
  

Tinea capitis

• Griseofulvin Microsize 10-20mg/kg/day div Q12-24 (max 1000mg/day) OR Griseofulvin Ultramicrosize >2 years 5-10mg/kg/day div Q12-24 x6 weeks] AND Selenium sulfide shampoo twice weekly x1 week as directed.

Necrotizing Fasciitis

1. Prompt surgical debridement and cultures. Send for cultures and sensitivities.
   
2. Treat with clindamycin AND Zosyn OR cefotaxime. For proven streptococcal disease, penicillin and clindamycin suffice.

Animal bites	Rabies prone: BATS, feral cats, raccoon, skunk, foxes, coyotes, most carnivores, woodchucks and livestock in certain areas	Treat all bat and feral cat exposures with both HRIG and Rabies vaccine as below. Otherwise, treat with vaccine and contact public health officials or infection control for advice on whether to treat with HRIG. Monitor animal for 10 days. Rabies vaccine 1 mL;IM into deltoid days 0, 3, 7, 14 and 28. HRIG 20 IU/kg around wound and begin vaccination series with HDCV or;RVA vaccine days 0, 3, 7, 14 and 28. Consider treating with Augmentin as below.
	Non Rabies-prone: Rodents, rabbits, hares, squirrels, hamsters, guinea pigs, gerbils, rats, chipmunks and mice usually do not require anti-rabies therapy. Consult public health officials with concerns. Check tetanus status. Consider Augmentin as below.
	Cat: Pasteurella multocida, S. aureus	Augmentin 45mg/kg/day div Q8-12 x5-7 days. For penicillin allergic patients, Pasteurella is covered by doxycycline or ciprofloxacin. Add another drug for Strep;or Staph sp. Rabies: See above if feral cat. Check tetanus status.
	Dog: Pasteurella multocida, S. aureu's, Bacteroides, Fusobacterium, Capnophaga	Augmentin 45mg/kg/day PO div Q8-12 x5-7 days Rabies: see above. Check tetanus status.
	Human: Strep viridans;(100%), Staph epinephrine (53%), Cornybacterium (41%), S. aureus (29%), Eikenella, Bacteroides, Peptostrep	High rates of infection. Do not close open wounds! Early (no signs of infection): Augmentin 45mg/kg/day PO div Q8-12 x5-7 days. Late (signs of infection): Ampicillin-sulbactam IV. Can use clindamycin AND ampicillin. Check tetanus status.
	Rat or pig (polymicrobial, Sprillum minus, Streptobacillus)	Augmentin 45mg/kg/day PO div Q8-12 x5-7 days Rabies: see above. Check tetanus status.
Lymphadenitis	Localized infection: GAS, S. aureus (MRSA)...less likely anaerobes, M. Tb (scrofula), Toxoplasmosis, Tularemia, Sporotrichosis,;atypical mycobacterial (consider the latter if nonresponsive to antimicrobials)	MSSA: Augmentin 90mg/kg/day PO div BID OR Cephalexin 100mg/kg/day PO div QID x10 days. If IV needed, cefazolin 100mg/kg/day IV div Q8. MRSA: Clindamycin OR TMP-SMX OR linezolid OR vancomycin (age based dosing) x7-10 days total.
	Cat-scratch disease: Bartonella henslae	Lymphadenitis common in axillary/epitrochlear nodes (46%), neck (26%), inguinal (17%). Treat for immunocompromised host of signs of systemic illness;(HSM). Azithromycin 10mg/kg/day PO Q24 x5 days. May also use Bactrim, rifampin and ciprofloxacin. Duration of therapy is uncertain.

Orthopedic Infections

Osteomyelitis

Risk Factor	Likely Organism	Initial Empiric Antibiotic Therapy'
Elderly, hematogenous spread	MRSA, MSSA, gram neg	Vancomycin 1gm + (Piperacillin/Tazobactam 3.375 grams OR imipenem 500mg)
Sickle Cell Disease	Salmonella, gram-negative bacteria	Ceftriaxone 50mg/kg IV once daily OR Cefotaxime 50mg/kg IV three times daily, PLUS Vancomycin 15mg/kg IV four times daily OR Clindamycin 10mg/kg IV PO four times daily OR Nafcillin 50 mg/kg IV four times daily to cover K. Kingae (common in daycare population)
DM or vascular insufficiency	Polymicrobial: Staph, strep, coliforms, anaerobes	Vancomycin 1gm + (Piperacillin/Tazobactam 3.375 grams OR imipenem 500mg)
IV drug user	MRSA, MSSA, pseudomonas	Vancomycin 1gm
Newborn	MRSA, MSSA, GBS, Gram Negative	Vancomycin 15mg/kg load, then reduce dose, AND ceftazidime 30mg/kg IV q12 h
Children	MRSA, MSSA	Vancomycin 10mg/kg q6 h AND ceftazidime 50mg/kg q8hr
Postoperative (ortho)	MRSA, MSSA	Vancomycin 1gm
Human bite	Strep, anaerobes, HACEK organism	Piperacillin/Tazobactam 3.375gm OR imipenem 500mg
Animal bites	Pasteurella, Eikenella, HACEK organism	Piperacillin/Tazobactam 3.375gm OR imipenem 500mg
Foot puncture wound	Pseudomonas	Anti-pseudomonal, staph coverage

Septic Arthritis

• If immunized against Hib: Nafcillin 200mg/kg/day IV div Q6 OR cefazolin 100mg/kg/day div Q8 x21 days.
• If unimmunized again Hib: Cefuroxime OR cefotaxime AND nafcillin OR cefazolin x21 days.
• If Gonococcus suspected or isolated, ceftriaxone 50mg/kg/day IV/IM daily OR penicillin G IV (if susceptible) x7-10 days.

See Also

Antibiotics by diagnosis

• Bone and joint antibiotics
• Cardiovascular antibiotics
• ENT antibiotics
• Eye antibiotics
• GI antibiotics
• GU antibiotics
• Neuro antibiotics
• OB/GYN antibiotics
• Pulmonary antibiotics
• Skin and soft tissue antibiotics
• Bioterrorism antibiotics
• Environmental exposure antibiotics
• Immunocompromised antibiotics
• Post exposure prophylaxis antibiotics
• Pediatric antibiotics
• Sepsis antibiotics
• Arthropod and parasitic antibiotics

For antibiotics by organism see Microbiology (Main)