What is the recommended treatment guideline for bacteremia in children?

Treatment Guidelines for Bacteremia in Children

The recommended treatment for bacteremia in children depends on the child's age, suspected source of infection, and local antimicrobial resistance patterns, with specific empiric antibiotic regimens tailored to age groups: ampicillin plus ceftazidime or gentamicin for infants 8-21 days old, ceftriaxone for those 22-60 days old, and targeted therapy based on culture results for older children. 1

Age-Based Empiric Treatment Recommendations

Infants 8-21 Days Old

• No focus identified: Ampicillin IV/IM (150 mg/kg/day divided every 8h) AND either:
  • Ceftazidime IV/IM (150 mg/kg/day divided every 8h) OR
  • Gentamicin IV/IM (4 mg/kg/dose every 24h) 1
• Bacterial meningitis: Ampicillin IV/IM (300 mg/kg/day divided every 6h) AND ceftazidime IV/IM (150 mg/kg/day divided every 8h) 1

Infants 22-28 Days Old

• No focus identified: Ceftriaxone IV/IM (50 mg/kg/dose every 24h) 1
• Bacterial meningitis: Ampicillin IV/IM (300 mg/kg/day divided every 6h) AND ceftazidime IV/IM (150 mg/kg/day divided every 8h) 1

Infants 29-60 Days Old

• No focus identified: Ceftriaxone IV/IM (50 mg/kg/dose every 24h) 1
• Bacterial meningitis: Ceftriaxone IV (100 mg/kg/day once daily or divided every 12h) OR ceftazidime IV (150 mg/kg/day divided every 8h) AND vancomycin IV (60 mg/kg/day divided every 8h) 1

Treatment for Older Children with Bacteremia

S. aureus Bacteremia (Children 1-17 Years)

• IV vancomycin is the recommended treatment 1
• If the patient is stable without ongoing bacteremia or intravascular infection:
  • Clindamycin 10-13 mg/kg/dose IV every 6-8h (if local resistance <10%) with transition to oral therapy if susceptible 1
  • Linezolid may be considered: 600 mg PO/IV twice daily for children >12 years and 10 mg/kg/dose every 8h for children <12 years 1

Duration of Therapy

• Uncomplicated bacteremia: Minimum 14 days 1
• Complicated bacteremia: 4-6 weeks depending on extent of infection 1
• Infective endocarditis: At least 4-6 weeks 1

Important Clinical Considerations

Diagnostic Approach

• Blood cultures should be obtained before initiating antibiotics
• Consider the volume of blood cultured - low-level bacteremia is common in children, requiring adequate blood volume for reliable detection 2
• Repeat blood cultures 2-4 days after initial positive cultures to document clearance of bacteremia 1

Monitoring and Follow-up

• For hospitalized patients, monitor for:
  • Clinical improvement (fever resolution within 72h of appropriate therapy)
  • Clearance of bacteremia
  • Development of complications 1

Pitfalls to Avoid

1. Inadequate blood volume for cultures - Low-level bacteremia is common in pediatric patients (60.3% have ≤10 CFU/ml), which can lead to false-negative results 2
2. Delayed antibiotic administration - Gram-negative bacteremia may have longer time to antibiotic administration than vaccine-preventable bacteremia 3
3. Not considering local resistance patterns - Use of local antibiogram is essential for guiding empiric therapy 1
4. Premature switch to narrow-spectrum antibiotics - Wait for culture and susceptibility results before de-escalating therapy 1
5. Inadequate duration of therapy - Bacteremia requires prolonged treatment, especially with endovascular sources 1

Changing Epidemiology of Pediatric Bacteremia

The etiology of pediatric bacteremia has evolved with increasing vaccine coverage:

• Decrease in vaccine-preventable bacteria (S. pneumoniae, H. influenzae type b, N. meningitidis)
• Increase in healthcare-associated bacteremias (S. aureus and Gram-negative bacteria) 3
• Reduced susceptibility to empirical antibiotics over time (from 96.3% to 82.6%) 3

This changing epidemiology emphasizes the importance of:

1. Appropriate empiric antibiotic selection based on age and risk factors
2. Prompt administration of antibiotics
3. Adjustment of therapy based on culture and susceptibility results

Remember that bacteremia treatment should be modified following results of cultures and sensitivities, and local antibiogram data should guide empiric choices whenever available 1.