What is the recommended treatment for bacteremia in children?

Treatment of Bacteremia in Children

The recommended treatment for bacteremia in children is age-specific: 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 Therapy

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) 2, 1

• Bacterial meningitis:

  • Ampicillin IV/IM (300 mg/kg/day divided every 6h) AND
  • Ceftazidime IV/IM (150 mg/kg/day divided every 8h) 2, 1

Children 22-28 days old:

• No focus identified or UTI:
  • Ceftriaxone IV/IM (50 mg/kg/dose every 24h) 2, 1

Children 29-60 days old:

• No focus identified:
  • Ceftriaxone IV/IM (50 mg/kg/dose every 24h) 2
• UTI:
  • Ceftriaxone IV/IM (50 mg/kg/dose every 24h) OR
  • Oral options for infants >28 days: Cephalexin 50-100 mg/kg/day in 4 doses or cefixime 8 mg/kg/day in 1 dose 2

Children >60 days old:

• Therapy should be guided by suspected source, clinical presentation, and local antibiogram patterns 1

Specific Pathogen Considerations

MRSA Bacteremia:

• Vancomycin 15 mg/kg/dose IV q6h 2
• Alternatives:
  • Linezolid 10 mg/kg/dose PO/IV q8h (not to exceed 600 mg/dose) for children <12 years 2, 1
  • Daptomycin 6-10 mg/kg/dose IV daily 2

Duration of Therapy

• Uncomplicated bacteremia: Minimum of 14 days 1
• Complicated bacteremia: 4-6 weeks depending on extent of infection 1
• Catheter-related bloodstream infections: 10-14 days assuming clinical and microbiological response within 48-72h 2

Key Diagnostic Considerations

• Blood cultures should be obtained before initiating antibiotics 1
• For catheter-related infections, paired quantitative blood cultures from both the catheter and peripheral vein should be obtained 2
• Low-level bacteremia is common in children (60.3% of cases have ≤10 CFU/ml), requiring adequate blood volume for culture 3

Monitoring and Follow-up

• Repeat blood cultures 2-4 days after initial positive cultures to document clearance 1
• Monitor for clinical improvement (fever resolution within 72h of appropriate therapy) 1
• For catheter-related infections, catheter removal is recommended with clinical deterioration, persistent bacteremia, or suppurative complications 2

Common Pathogens and Changing Epidemiology

• Streptococcus pneumoniae, Neisseria meningitidis, and Staphylococcus aureus are common pathogens 4, 5
• Pneumococcal conjugate vaccine has reduced pneumococcal bacteremia by 49% 4
• Increasing rates of gram-negative infections (6.7% annual increase) and healthcare-associated bacteremia have been observed 4
• E. coli is the most common isolate in children under three months 5

Important Pitfalls to Avoid

• Delayed antibiotic administration: Gram-negative bacteremia often experiences longer delays to antibiotics (57 minutes longer than vaccine-preventable bacteremia) 4
• Inadequate blood volume for cultures: Due to common low-level bacteremia in children, inadequate sampling may lead to false negatives 3
• Ignoring local resistance patterns: Use of local antibiogram is essential for guiding empiric therapy 2, 1
• Premature de-escalation: Wait for culture and susceptibility results before narrowing therapy 1

Remember that bacteremia treatment requires prompt recognition, appropriate empiric antibiotic selection based on age and suspected source, and adjustment based on culture results to ensure optimal outcomes.