Antimicrobial Usage Guidelines for Pediatrics in Indian Hospitals
Based on IAP Standard Treatment Guidelines and ICMR Guidelines, antimicrobial therapy for pediatric infectious syndromes should follow a structured, risk-stratification approach that prioritizes appropriate empiric coverage while minimizing antimicrobial resistance.
Neuroinfections
Bacterial Meningitis
| Risk Category | First-line Treatment | Alternative Treatment | Duration |
|---|---|---|---|
| Community-acquired | Ceftriaxone 50 mg/kg IV BD or Cefotaxime 50 mg/kg IV QDS [1] | Ampicillin + Gentamicin (for infants <3 months) | 7-10 days (21 days for meningitis) [1] |
| Hospital-acquired | Ceftazidime 50 mg/kg IV TDS + Vancomycin | Meropenem + Vancomycin | 14-21 days |
| Neonatal | Ampicillin 50 mg/kg IV QDS + Gentamicin 5-7.5 mg/kg IV daily [1] | Cefotaxime + Amikacin | 21 days |
- Monitor CSF sterilization with repeat lumbar puncture in complicated cases
- Consider dexamethasone before or with first dose of antibiotics for suspected pneumococcal meningitis
Respiratory Infections
Community-Acquired Pneumonia
| Risk Category | First-line Treatment | Alternative Treatment | Duration |
|---|---|---|---|
| Mild (outpatient) | Amoxicillin 40 mg/kg/day oral BD | Azithromycin (for atypical pneumonia) | 5-7 days |
| Moderate (inpatient) | Ampicillin 50 mg/kg IV QDS [1] | Ceftriaxone 50 mg/kg IV daily | 5-7 days |
| Severe | Ampicillin 50 mg/kg IV QDS + Gentamicin 7.5 mg/kg IV daily [1] | Ceftriaxone 80 mg/kg IV daily | At least 5 days [1] |
| Staphylococcal pneumonia | Cloxacillin 50 mg/kg IV QDS + Gentamicin 7.5 mg/kg IV daily [1] | Vancomycin + Ceftriaxone | 7-10 days, then oral cloxacillin to complete 3 weeks [1] |
Pleural Infection/Empyema
- All cases should be treated with intravenous antibiotics covering Streptococcus pneumoniae 1
- Broader spectrum coverage for hospital-acquired infections, post-surgical, trauma, or aspiration 1
- Antibiotic choice should be guided by microbiology results when available 1
- Continue oral antibiotics for 1-4 weeks after discharge, longer if residual disease 1
Urinary Tract Infections
| Risk Category | First-line Treatment | Alternative Treatment | Duration |
|---|---|---|---|
| Uncomplicated lower UTI | Co-trimoxazole 10 mg/kg (TMP) + 40 mg/kg (SMX) oral BD [1] | Cefixime | 5-7 days |
| Complicated/Pyelonephritis | Ampicillin IV + Gentamicin IV (as per sepsis dosing) [1] | Ceftriaxone 50-75 mg/kg/day [1] | 10-14 days |
| Hospital-acquired | Piperacillin-tazobactam 200-300 mg/kg/day (piperacillin component) IV divided q6-8h [1] | Meropenem 60 mg/kg/day IV q8h [1] | 10-14 days |
- Adjust therapy based on urine culture and sensitivity results
- Consider imaging studies for recurrent UTIs or pyelonephritis
Intra-abdominal Infections
| Risk Category | First-line Treatment | Alternative Treatment | Duration |
|---|---|---|---|
| Community-acquired | Ampicillin + Gentamicin + Metronidazole | Ceftriaxone 50-75 mg/kg/day + Metronidazole [1] | 5-7 days if source control achieved |
| Hospital-acquired/Complicated | Piperacillin-tazobactam 200-300 mg/kg/day (piperacillin component) IV divided q6-8h [1,2] | Meropenem 60 mg/kg/day IV q8h [1] | 7-10 days |
| Necrotizing enterocolitis (neonates) | Ampicillin + Gentamicin + Metronidazole OR Ampicillin + Cefotaxime + Metronidazole OR Meropenem [1] | Add Vancomycin for suspected MRSA or ampicillin-resistant enterococci [1] | 10-14 days |
- Add fluconazole or amphotericin B if fungal infection is suspected 1
- Duration depends on adequate source control and clinical response
Skin and Soft Tissue Infections
| Risk Category | First-line Treatment | Alternative Treatment | Duration |
|---|---|---|---|
| Impetigo | Dicloxacillin 12 mg/kg/day oral in 4 divided doses [1] | Cephalexin 25 mg/kg/day oral in 4 divided doses [1] | 5-7 days |
| MSSA infections | Cloxacillin/Flucloxacillin 50 mg/kg IV QDS [1] | Cefazolin 50 mg/kg/day IV in 3 divided doses [1] | 7-10 days |
| MRSA infections | Vancomycin 40 mg/kg/day IV in 4 divided doses [1] | Linezolid 10 mg/kg IV/oral every 12h [1] | 7-14 days |
| Necrotizing infections | Piperacillin-tazobactam + Clindamycin + Vancomycin [2] | Meropenem + Clindamycin + Vancomycin | 14-21 days |
- Surgical debridement is essential for abscesses and necrotizing infections
- Adjust therapy based on culture results and clinical response
Hospital-Acquired Infections
Hospital-Acquired Pneumonia
| Risk Category | First-line Treatment | Alternative Treatment | Duration |
|---|---|---|---|
| Early-onset (<5 days) | Ampicillin-sulbactam 200 mg/kg/day (ampicillin component) IV q6h [1] | Ceftriaxone + Clindamycin | 7-10 days |
| Late-onset (≥5 days) | Piperacillin-tazobactam 200-300 mg/kg/day (piperacillin component) IV divided q6-8h [1] | Meropenem 60 mg/kg/day IV q8h [1] | 10-14 days |
| Ventilator-associated | Piperacillin-tazobactam + Amikacin 15-22.5 mg/kg/day IV q8-24h [1] | Meropenem + Vancomycin | 10-14 days |
Neonatal Sepsis
| Risk Category | First-line Treatment | Alternative Treatment | Duration |
|---|---|---|---|
| Early-onset (<72h) | Ampicillin 50 mg/kg IV QDS + Gentamicin 5-7.5 mg/kg IV daily [1] | Cefotaxime + Gentamicin | 7-10 days |
| Late-onset (≥72h) | Vancomycin + Amikacin | Meropenem + Vancomycin | 10-14 days |
| NICU-acquired | Piperacillin-tazobactam + Amikacin | Meropenem + Vancomycin | 10-14 days |
- Consider ESBL-producing Klebsiella pneumoniae in NICU settings 3
- Implement strict infection control measures to prevent outbreaks
Important Considerations
Dosing accuracy: Use weight-based dosing with accurate weight measurement. When scales are unavailable, consider age-based formulae or tools like the Broselow Tape 1.
Antimicrobial stewardship: Avoid unnecessary broad-spectrum antibiotics. De-escalate therapy based on culture results.
Duration optimization: Shorter courses (5-7 days) are appropriate for most uncomplicated infections with good clinical response 1, 2.
Monitoring: Regular assessment of clinical response within 48-72 hours of initiating therapy. Monitor inflammatory markers and adjust therapy accordingly 2.
Local resistance patterns: Consider local antimicrobial resistance patterns when selecting empiric therapy, especially for hospital-acquired infections 2, 3.
Pediatric formulations: Ensure appropriate pediatric formulations are available, particularly for oral therapy after IV-to-oral switch 1.
Nursing care: Pediatric OPAT requires nursing staff with specific pediatric competencies and experience in physical assessment of infants and children 1.
This guideline provides a framework for antimicrobial therapy in pediatric infections based on risk stratification. Always consider local resistance patterns and adjust therapy based on culture results when available.