What is the recommended treatment for bacteremia in children?

Treatment of Bacteremia in Children

For children with bacteremia, intravenous vancomycin is the recommended first-line treatment, with clindamycin as an alternative for stable patients without ongoing bacteremia when local resistance rates are low (<10%). 1

Initial Assessment and Diagnosis

When evaluating a child with suspected bacteremia:

• Obtain blood cultures from all lumens of central venous catheters if present 1
• Consider obtaining peripheral blood cultures concurrently with central venous catheter cultures 1
• Consider urinalysis and urine culture to identify potential urinary source 1
• Obtain chest radiography only if respiratory signs or symptoms are present 1

Treatment Algorithm Based on Risk Stratification

High-Risk Bacteremia

1. First-line therapy:

   • IV vancomycin 15 mg/kg/dose every 6 hours 1

2. Alternative options:

   • Clindamycin 10-13 mg/kg/dose IV every 6-8 hours (total 40 mg/kg/day) if:
     • Patient is stable
     • No ongoing bacteremia
     • No intravascular infection
     • Local clindamycin resistance rate is <10% 1
   • Linezolid (for children >12 years: 600 mg PO/IV twice daily; for children <12 years: 10 mg/kg/dose every 8 hours) 1

3. Duration of therapy:

   • Uncomplicated bacteremia: minimum 2 weeks
   • Complicated bacteremia: 4-6 weeks depending on extent of infection 1

Special Considerations

MRSA Bacteremia

• Follow recommendations for high-risk bacteremia
• Do not add gentamicin or rifampin to vancomycin for native valve infective endocarditis or uncomplicated bacteremia 1
• Perform clinical assessment to identify and eliminate/debride source of infection 1
• Obtain follow-up blood cultures 2-4 days after initial positive cultures to document clearance 1
• Consider echocardiography in children with congenital heart disease, bacteremia >2-3 days, or other findings suggestive of endocarditis 1

Gram-negative Bacteremia

• Use monotherapy with an antipseudomonal β-lactam, fourth-generation cephalosporin, or carbapenem 1
• Reserve addition of a second gram-negative agent for patients who are clinically unstable or when resistant infection is suspected 1

Monitoring and Follow-up

• Obtain additional blood cultures 2-4 days after initial positive cultures to document clearance of bacteremia 1
• Monitor for clinical improvement (defervescence within 72 hours of initiating therapy) 1
• Evaluate for potential metastatic sites of infection 1

Common Pitfalls and Caveats

1. Low-level bacteremia is common in children: Studies show that 60% of pediatric bacteremia episodes involve low concentrations of pathogens (≤10 CFU/ml), making adequate blood volume collection critical for diagnosis 2

2. Empiric therapy considerations: The decision to use empiric antibiotics should be based on clinical presentation and risk factors, as routine use of oral antibiotics in all febrile children without focal infection is not supported by evidence 3

3. Resistance patterns: Local resistance patterns should guide therapy choices, as studies have shown declining susceptibility to common antibiotics in pediatric bacteremia 4

4. Treatment efficacy: Children who receive appropriate antibiotic therapy at initial presentation are more likely to show clinical improvement and less likely to develop persistent bacteremia or new focal infections compared to those who receive no antibiotics 5

5. Targeted therapy: While broad empiric coverage is initially important, narrowing therapy based on culture results is essential to prevent antimicrobial resistance 6