Antibiotic Choices for Infections which Require Hospitalization

1. Antibiotic Choices for Infections which Require Hospitalization Rodolfo E. Bégué, MD Chief, Infectious Diseases Pediatrics, LSUHSC rbegue@lsuhsc.edu

2. Infections which require hospitalization Examples:r/o sepsismeningitis / encephalitisbrain abscess / orbital cellulitispneumonia / endocarditisacute abdomenurinary tract infection bone & jointskin & skin structures

3. Fever  r/o sepsis • Hyperthermia or hypothermia • Tachycardia • Tachypnea • Leukocytosis or leukopenia • Toxicity = clinical picture - lethargy - hypoperfusion - hypoventilation, hyperventilation or cyanosis.

4. Sepsis work-up • Cell Blood Count (CBC)  Blood Culture • Urine analysis  Urine Culture • Chest roentgenogram • Stool • NPA • Lumbar puncture  CSF Culture • (CRP, Procalcitonin)

5. < 1 month of age Group B Streptococcus Escherichia coli (Listeria monocytogenes) Etiologies of Sepsis • 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)

6. Antibiotics for a child with r/o Sepsis Empiric Antibiotic Treatment:< 1 month: Ampicillin + Gentamicin Ampicillin + Cefotaxime1-3 months: Ampicillin + Cefotaxime> 3 months: Cefotaxime (Vancomycin?)x 7-14 days

7. 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”)

8. 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

9. Bacterial Meningitis • Diagnosis: LP, LP, LP • Should I do an LP? • Increased intracranial pressure • Prior antibiotics • “Bloody tap”

10. Bacterial Meningitis: Treatment • Neonate:Amp+Gent / Amp+Cefotax • Older child: cefotaxime plus vancomycin • Modify according to susceptibilities:penicillin cefotaxime vancomycin plus cefotaxime • Corticosteroids (?) • Rifampin (?)

11. Aseptic Meningitis • Viral (enterovirus vs others) • “Partially treated” • Other causes only on special populations

12. Encephalitis • Not bacterial • HSV Enterovirus Arbovirus (WNV) EBV, CMV, etc • ADEM

13. HSV Encephalitis Acyclovir:60 mg/kg/d div q 8 hr750 mg/m2/d div q 8 hrx 21 days IV

14. Brain abscess Source: • Proximity: middle ear, sinuses • Meningitis • Hematogenous • Penetrating: wound, surgery

15. Brain abscess Triad: • Headache • Focal neurologic findings • Fever • Treatment: • Surgery • Antibiotics: Cefotax + Vanco + (Metro) • for 4-8 weeks (IV)

16. Orbital Cellulitis Triad: • Proptosis • Decreased eye movement • Pain on eye movement

17. Orbital Cellulitis Treatment: • Antibiotics:Cefotax + Vanco + (Metro) Cefotax + Clindax 10-14 d IV and 7-14 d PO • Surgery (ORL, Ophthalmology)

18. HSV Keratitis Management: • With an ophthalmologist • antivirals: 1-2% trifluridine1% iododeoxyuridine3% vidarabinex 14-21 days • topical corticosteroids contraindicated • No need for systemic acyclovir

19. Viral:Influenza, RSV BacterialStreptococcus pneumoStaph aureusGroup A Streptococcus TB ChlamydiaMycoplasma Fungal Pneumonia

20. 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

21. Endocarditis • Acute  Staph (MRSA) • Subacute  viridans Strept • Antibiotics: Vanco + gentamicin Penicillin + gentamicin • X 2 w, 4-6 w • Surgery (?)

22. Pericarditis • “Purulent pericarditis” • Strept PneumoStaph aureus (MRSA) • Antibiotics: Ceftriaxone + Vancomycin • X 4 weeks • Surgery (?)

23. Acute Abdomen Diagnosis: • Clinical • Imaging (XR, US, CT) Treatment • Surgery • Antibiotics For 5-7 days IDSA. CID 2010;50:133-64 PO Cipro/Metro or Amox/Clav x 14-21 d

24. 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

25. Urinary Tract Infection • Inpatient Treatment • Cefotaxime or Ceftriaxone • Ampicillin + gentamicin • Follow-up • US, VCUG • DMSA scan • Consider prophylaxis

26. Osteomyelitis • Staph aureus • (Others in especial populations) • ClindamycinVancomycinLinezolid • X 4 weeks (IV/PO) • Surgery

27. Septic arthritis • Fever, joint pain/swelling, decreased ROM • Diagnosis: clinical, XR (hip), US, arthrocentesis, CT (SI)

28. Septic arthritis • Etiologies: • Staph aureus • Streptococcus (GAS, Strept pneumo) • Kingella kingaeSalmonella • Neisseria (GC, N. meningitidis) • (H. influenzae) Treatment: • Aspirate vs Surgery: hips, shoulders • Antibiotics:Vancomycin (Clinda, Oxacillin)+ cefotaxime (cefuroxime) • x 3 weeks (IV/PO)

29. 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) Puncture wounds (foot)

30. Skin and Soft Tissue • Etiology:Group A Streptococcus Staphylococcus aureus (MRSA)(Strep pneumo / Hib) • Treatment:Vancomycin or Clindamycinadd rifampin?linezolid?? • Drain any abscess

31. Any Question?