What are the guidelines for antibiotic use in all pediatric patients?

Guidelines for Antibiotic Use in Pediatric Patients

Antibiotic selection for pediatric patients should be based on the specific infection site, severity of illness, and local resistance patterns, with narrow-spectrum agents preferred whenever possible to minimize antimicrobial resistance.

Respiratory Tract Infections

Bronchitis and Pneumonia

• First-line treatment for bacterial bronchitis/pneumonia:

  • Amoxicillin 80-100 mg/kg/day divided into 3 doses 1
  • For children <5 years: 90 mg/kg/day in 2 doses
  • For children ≥5 years: 90 mg/kg/day in 2 doses (maximum 4 g/day) 1

• Alternative options:

  • Amoxicillin-clavulanate (when beta-lactamase-producing pathogens suspected) 1
  • Oral cephalosporins (cefuroxime-axetil, cefpodoxime-proxetil) for non-anaphylactic penicillin allergy 1
  • Macrolides (e.g., azithromycin) for penicillin allergy or atypical pathogens 1

• Duration of treatment:

  • Uncomplicated pneumonia: 5-7 days
  • Bacteremic pneumonia: 10-14 days
  • Severe pneumonia: 10 days (extended to 14-21 days for complicated cases) 1
  • Acute bronchitis: 5-8 days
  • Bacterial bronchitis: 14 days (up to 4 weeks for recurrent cases) 1

Bronchiolitis

• Primarily viral - antibiotics not routinely recommended unless bacterial co-infection suspected 1

Intra-abdominal Infections

Empiric Therapy Options

• Aminoglycoside-based regimen:

  • Amikacin: 15-22.5 mg/kg/day every 8-24h
  • Gentamicin: 3-7.5 mg/kg/day every 8-24h
  • Tobramycin: 3.0-7.5 mg/kg/day every 8-24h 2

• Carbapenems:

  • Ertapenem: 15 mg/kg twice daily (≤12 years), 1 g/day (≥13 years)
  • Imipenem-cilastatin: 60-100 mg/kg/day every 6h
  • Meropenem: 60 mg/kg/day every 8h 2

• Beta-lactam/beta-lactamase inhibitors:

  • Piperacillin-tazobactam: 200-300 mg/kg/day of piperacillin component every 6-8h
  • Ticarcillin-clavulanate: 200-300 mg/kg/day of ticarcillin component every 4-6h 2

• Cephalosporins with metronidazole:

  • Cefotaxime: 150-200 mg/kg/day every 6-8h
  • Ceftriaxone: 50-75 mg/kg/day every 12-24h
  • Ceftazidime: 150 mg/kg/day every 8h
  • Cefepime: 100 mg/kg/day every 12h
  • Metronidazole: 30-40 mg/kg/day every 8h 2

Special Considerations

• For severe beta-lactam allergies: ciprofloxacin (20-30 mg/kg/day every 12h) plus metronidazole or aminoglycoside-based regimen 2
• Necrotizing enterocolitis in neonates: ampicillin, gentamicin, and metronidazole; or ampicillin, cefotaxime, and metronidazole; or meropenem 2

Skin and Soft Tissue Infections

Mild Infections

• First-line options:
  • Amoxicillin-clavulanic acid
  • Cloxacillin
  • Cefalexin 2

Necrotizing Fasciitis

• Recommended regimens:
  • Clindamycin + piperacillin-tazobactam (with or without vancomycin)
  • Ceftriaxone + metronidazole (with or without vancomycin) 2

Urinary Tract Infections

Neonates (<28 days)

• Hospitalization with parenteral amoxicillin and cefotaxime
• Complete 14 days total therapy (transition to oral after clinical improvement) 3

Infants (28 days to 3 months)

• Clinically ill: Hospitalize with parenteral 3rd generation cephalosporin or gentamicin
• Not acutely ill: Outpatient management with daily ceftriaxone or gentamicin until afebrile
• Complete 14 days total therapy 3

Children with Pyelonephritis

• Complicated: Hospitalize with parenteral ceftriaxone or gentamicin until improved
• Uncomplicated: Outpatient parenteral ceftriaxone or gentamicin until afebrile
• Complete 10-14 days total therapy 3

Children with Cystitis

• Oral antibiotics for 5-7 days 3

Dosing Considerations

Amoxicillin Dosing

• For children <40 kg:

  • Mild/moderate infections: 25 mg/kg/day divided every 12h or 20 mg/kg/day divided every 8h
  • Severe infections: 45 mg/kg/day divided every 12h or 40 mg/kg/day divided every 8h 4

• For children <12 weeks:

  • Maximum 30 mg/kg/day divided every 12h due to immature renal function 4

Clindamycin Dosing

• Serious infections: 8-16 mg/kg/day divided into 3-4 equal doses
• Severe infections: 16-20 mg/kg/day divided into 3-4 equal doses 5
• For beta-hemolytic streptococcal infections: minimum 10-day treatment 5

Key Principles for Antibiotic Use

1. Appropriate selection: Match antibiotic to suspected pathogen and site of infection
2. Narrow-spectrum when possible: Avoid broad-spectrum agents when narrow-spectrum options are effective 1
3. Appropriate duration: Treat for recommended duration based on infection type and severity
4. Monitoring: Assess clinical improvement within 48-72 hours; consider changing antibiotics if no improvement 1
5. Supportive care: Ensure adequate oxygenation, hydration, and nutrition alongside antibiotic therapy 1

Common Pitfalls to Avoid

1. Overuse of broad-spectrum antibiotics: Studies show high rates of azithromycin prescribing (47%) for pediatric pneumonia despite guidelines recommending amoxicillin 6
2. Unnecessary antibiotic exposure: One study found 46.4% of children received antibiotics for suspected UTI despite negative cultures 7
3. Inappropriate dosing: This is a common reason for non-adherence to guidelines 8
4. Regional prescribing variations: Significant differences in amoxicillin prescribing exist between regions, with lower rates in the Midwest and South compared to the Northeast 6
5. Failure to adjust therapy based on culture results: Implement processes to discontinue antibiotics for negative cultures 7

By following these evidence-based guidelines and avoiding common pitfalls, clinicians can optimize antibiotic therapy for pediatric patients while minimizing unnecessary antibiotic exposure and resistance development.