Antibiotic Choices for Infections which Require Hospitalization

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Antibiotic Choices for Infections which Require
Hospitalization

• Rodolfo E. Bégué, MD
• Chief, Infectious Diseases
• Pediatrics, LSUHSC
• rbegue_at_lsuhsc.edu

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Infections which require hospitalization

• Examplesr/o sepsismeningitis /
  encephalitisbrain abscess / orbital
  cellulitispneumonia / endocarditisacute
  abdomenurinary tract infection bone
  jointskin skin structures

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Fever ? r/o sepsis

• Hyperthermia or hypothermia
• Tachycardia
• Tachypnea
• Leukocytosis or leukopenia
• Toxicity clinical picture - lethargy -
  hypoperfusion - hypoventilation,
  hyperventilation or cyanosis.

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Sepsis work-up

• Cell Blood Count (CBC) ? Blood Culture
• Urine analysis ? Urine Culture
• Chest roentgenogram
• Stool
• NPA
• Lumbar puncture ? CSF Culture
• (CRP, Procalcitonin)

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Etiologies of Sepsis

• lt 1 month of age
• Group B Streptococcus
• Escherichia coli
• (Listeria monocytogenes)

• 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)

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Antibiotics for a child with r/o Sepsis

• Empiric Antibiotic Treatmentlt 1
  month Ampicillin Gentamicin Ampicillin
  Cefotaxime1-3 months Ampicillin
  Cefotaximegt 3 months Cefotaxime
• (Vancomycin?)x 7-14 days

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Is it a contaminant?

• 1 vs gt2 positive culture
• Pathogen vs no pathogen
• Symptoms vs no symptoms
• Timing (lt 24 h vs gt 24 h)
• Plate vs broth (thio)

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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

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Bacterial Meningitis

• Diagnosis LP, LP, LP
• Should I do an LP?
• Increased intracranial pressure
• Prior antibiotics
• Bloody tap

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Bacterial Meningitis Treatment

• Neonate AmpGent / AmpCefotax
• Older child cefotaxime plus vancomycin
• Modify according to susceptibilities penicillin
  cefotaxime vancomycin plus cefotaxime
• Corticosteroids (?)
• Rifampin (?)

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Aseptic Meningitis

• Viral (enterovirus vs others)
• Partially treated
• Other causes only on special populations

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Encephalitis

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

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HSV Encephalitis

• Acyclovir60 mg/kg/d div q 8 hr750 mg/m2/d div
  q 8 hrx 21 days IV

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Brain abscess

• Source
• Proximity middle ear, sinuses
• Meningitis
• Hematogenous
• Penetrating wound, surgery

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Brain abscess

• Triad
• Headache
• Focal neurologic findings
• Fever

• Treatment
• Surgery
• Antibiotics Cefotax Vanco (Metro)
• for 4-8 weeks (IV)

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Orbital Cellulitis

• Triad
• Proptosis
• Decreased eye movement
• Pain on eye movement

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Orbital Cellulitis

• Treatment
• AntibioticsCefotax Vanco (Metro) Cefotax
  Clindax 10-14 d IV and 7-14 d PO
• Surgery (ORL, Ophthalmology)

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HSV Keratitis

• Management
• With an ophthalmologist
• antivirals 1-2 trifluridine1
  iododeoxyuridine3 vidarabinex 14-21 days
• topical corticosteroids contraindicated
• No need for systemic acyclovir

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Pneumonia

• TB
• ChlamydiaMycoplasma
• Fungal

• ViralInfluenza, RSV
• BacterialStreptococcus pneumoStaph aureusGroup
  A Streptococcus

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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

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Endocarditis

• Acute ? Staph (MRSA)
• Subacute ? viridans Strept
• Antibiotics Vanco gentamicin Penicillin
  gentamicin
• X 2 w, 4-6 w
• Surgery (?)

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Pericarditis

• Purulent pericarditis
• Strept PneumoStaph aureus (MRSA)
• Antibiotics Ceftriaxone Vancomycin
• X 4 weeks
• Surgery (?)

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Acute Abdomen

• Diagnosis
• Clinical
• Imaging (XR, US, CT)
• Treatment
• Surgery
• Antibiotics

Mild-moderate Severe
Ampi/sulb, Ticar/clav Piperac/Tazobactam Imipenem, Meropenem, Ertapenem
Cefazolin or cefuroxime metronidazole Cefotax, ceftriax, ceftaz, cefepime metronidazole
Ampi genta (Tobra) Metronidazole (Clinda) Cipro, levoflox, gatiflox Metronidazole Aztreonam Metronidazole
For 5-7 days
IDSA. CID 201050133-64
PO Cipro/Metro or Amox/Clav x 14-21 d
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Urinary Tract Infection

• Etiology
• Escherichia coli
• Enterococcus

• Always suspect in febrile children lt 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)

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Urinary Tract Infection

• Follow-up
• US, VCUG
• DMSA scan
• Consider prophylaxis

• Inpatient Treatment
• Cefotaxime or Ceftriaxone
• Ampicillin gentamicin

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Osteomyelitis

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

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Septic arthritis

• Fever, joint pain/swelling, decreased ROM
• Diagnosis clinical, XR (hip), US,
  arthrocentesis, CT (SI)

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Septic arthritis

• Treatment
• Aspirate vs Surgery hips, shoulders
• AntibioticsVancomycin (Clinda, Oxacillin)
  cefotaxime (cefuroxime)
• x 3 weeks (IV/PO)

• Etiologies
• Staph aureus
• Streptococcus (GAS, Strept pneumo)
• Kingella kingaeSalmonella
• Neisseria (GC, N. meningitidis)
• (H. influenzae)

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Puncture wounds (foot)

• 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)

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Skin and Soft Tissue

• EtiologyGroup A Streptococcus Staphylococcus
  aureus (MRSA)(Strep pneumo / Hib)
• TreatmentVancomycin or Clindamycinadd
  rifampin?linezolid??
• Drain any abscess

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Any Question?