What are the current recommendations for managing pediatric infectious diseases?

Current Recommendations for Managing Pediatric Infectious Diseases

Antimicrobial Stewardship: The Foundation of Modern Pediatric ID Management

The most critical advancement in pediatric infectious disease management is the implementation of antimicrobial stewardship programs (ASPs) that prioritize limiting antibiotic exposure, narrowing spectrum when possible, and using the shortest effective treatment duration to combat rising antimicrobial resistance. 1

Core Stewardship Principles

• Minimize antibiotic exposure whenever possible, as antibiotic exposure directly selects for antibiotic resistance 1
• Limit the spectrum of antimicrobial activity to specifically target the identified pathogen rather than using broad-spectrum agents empirically 1
• Use proper dosing to achieve minimal effective concentration at the infection site, which is critical for preventing resistance development 1
• Treat for the shortest effective duration, as 10-day courses have been best studied but shorter courses may be equally effective for mild disease managed outpatient 1

Priority Intervention Areas (2025 Expert Consensus)

Recent expert consensus identified three intersecting themes for pediatric ASP focus 2:

• Care Settings: Target high-impact areas including outpatient clinics and intensive care units where antibiotic misuse is most common 2
• Prescriptions: Prioritize shorter treatment durations and narrow-spectrum agents over prolonged broad-spectrum therapy 2
• Strategies: Implement outcome-based metrics, improve diagnostic stewardship, and routinely track patient outcomes to guide stewardship efforts 2

Community-Acquired Pneumonia: Evidence-Based Treatment Algorithms

Hospitalization Criteria

Children should be hospitalized for moderate to severe CAP defined by respiratory distress and hypoxemia (SpO2 <90% at sea level). 1

Additional hospitalization indications include 1:

• Infants <3-6 months of age with suspected bacterial CAP 1
• Suspected CA-MRSA or other high-virulence pathogens 1
• Concerns about home observation, compliance with therapy, or follow-up 1

ICU Admission Criteria

Children require ICU admission or continuous cardiorespiratory monitoring for 1:

• Invasive ventilation via endotracheal tube 1
• Noninvasive positive pressure ventilation (CPAP or BiPAP) 1
• Impending respiratory failure 1
• Pulse oximetry <92% on FiO2 ≥0.50 1
• Sustained tachycardia, inadequate blood pressure, or need for vasopressor support 1
• Altered mental status due to hypercarbia or hypoxemia 1

Empiric Antibiotic Selection for Hospitalized Children

For fully immunized infants and school-aged children admitted to hospital wards, ampicillin (150-200 mg/kg/day every 6 hours) or penicillin is preferred when local epidemiology shows lack of substantial high-level penicillin resistance in invasive S. pneumoniae. 1

For children who are not fully immunized, in regions with high-level penicillin resistance, or with life-threatening infection including empyema, use third-generation cephalosporins: ceftriaxone (50-100 mg/kg/day every 12-24 hours) or cefotaxime (150 mg/kg/day every 8 hours). 1, 3

For penicillin-resistant S. pneumoniae with MICs ≥4.0 μg/mL, increase ceftriaxone to 100 mg/kg/day 3

Atypical Pathogen Coverage

Add a macrolide (oral or parenteral) to β-lactam therapy for hospitalized children when M. pneumoniae and C. pneumoniae are significant considerations. 1

Preferred regimens 1:

• Azithromycin: 10 mg/kg on day 1, then 5 mg/kg/day once daily days 2-5 (oral) 1
• Azithromycin IV: 10 mg/kg on days 1 and 2, transition to oral when possible 1
• Alternatives: Clarithromycin 15 mg/kg/day in 2 doses or erythromycin 40 mg/kg/day in 4 doses 1
• For children >7 years: Doxycycline 2-4 mg/kg/day in 2 doses 1

MRSA Coverage

Add vancomycin (40-60 mg/kg/day every 6-8 hours) or clindamycin (40 mg/kg/day every 6-8 hours) to β-lactam therapy when clinical, laboratory, or imaging characteristics suggest S. aureus infection. 1, 4

Note that clindamycin resistance is increasing in certain geographic areas among S. pneumoniae and S. aureus 1

Treatment Duration

CA-MRSA infections may require longer treatment than S. pneumoniae infections, so pathogen-specific duration adjustments are necessary 1

Diagnostic Approach

Blood cultures should NOT be routinely performed in nontoxic, fully immunized children with CAP managed outpatient. 1

Blood cultures SHOULD be obtained in 1:

• Children requiring hospitalization for moderate to severe bacterial CAP, particularly complicated pneumonia 1
• Children who fail to demonstrate clinical improvement or have progressive symptoms after initiating antibiotics 1

Influenza Management

Antiviral Therapy

Oseltamivir is the preferred antiviral for influenza treatment and prophylaxis in children ≥2 weeks of age. 5

Treatment dosing (5-day course) 1, 5:

• Children ≥13 years: 75 mg twice daily 5
• Children 1-12 years, >40 kg: 75 mg twice daily 1, 5
• Children 23.1-40 kg: 60 mg twice daily 1, 5
• Children 15.1-23 kg: 45 mg twice daily 1, 5
• Children ≤15 kg: 30 mg twice daily 1, 5
• Infants 2 weeks to <1 year: 3 mg/kg twice daily 1, 5

Prophylaxis dosing 1, 5:

• Post-exposure: 10 days following close contact 5
• Seasonal: Up to 6 weeks during community outbreak 5
• Immunocompromised: May continue up to 12 weeks 5

Zanamivir (inhaled) is an alternative for children ≥7 years: 2 inhalations (10 mg total) twice daily for treatment, once daily for prophylaxis 1

Critical Timing

Initiate antiviral therapy within 48 hours of symptom onset for treatment and within 48 hours of exposure for prophylaxis. 5

For immunocompromised children with suspected influenza, start oseltamivir immediately without waiting for confirmatory testing, as early treatment provides maximal benefit 4

Special Populations: Immunocompromised Children

Start with third-generation parenteral cephalosporin (ceftriaxone 50-100 mg/kg/day or cefotaxime 150 mg/kg/day) as the backbone for hospitalized immunocompromised children with pneumonia. 4

Add a macrolide for atypical pathogen coverage, particularly in school-aged children 4

Add vancomycin or clindamycin (40-60 mg/kg/day IV divided every 6-8 hours) if CA-MRSA is suspected based on local epidemiology or necrotizing features 4

Comprehensive microbiologic workup should include 4:

• Blood cultures (two sets) before antibiotics 4
• Sputum or induced sputum for culture and Gram stain 4
• Nasopharyngeal swab for viral PCR panel (influenza, RSV) 4

Reassess clinical response at 48-72 hours; if no improvement, broaden coverage for opportunistic pathogens (Pneumocystis, fungi, atypical mycobacteria) 4

Common Pitfalls and How to Avoid Them

Avoid Routine Broad-Spectrum Therapy

The evidence strongly supports starting with narrow-spectrum agents when appropriate rather than reflexively using broad-spectrum antibiotics 1. Cefepime, for example, is NOT recommended as first-line for pediatric CAP and lacks atypical pathogen coverage 6.

Don't Overlook Atypical Pathogens

β-lactams alone do not cover M. pneumoniae and C. pneumoniae 3. For school-aged children and adolescents with pneumonia, consider adding macrolide coverage empirically 1, 4.

Monitor for Clinical Response

Children on adequate therapy should demonstrate clinical and laboratory signs of improvement within 48-72 hours. 1, 3, 4 Failure to improve warrants reassessment and possible therapy modification.

Renal Dosing Adjustments

For oseltamivir in adults with renal impairment, dose adjustments are required when creatinine clearance is ≤60 mL/minute 5. For moderate impairment (CrCl >30-60 mL/min), reduce to 30 mg twice daily for treatment 5.

Emerging Challenges in Pediatric ASPs

Pediatric and neonatal ICUs present unique challenges for traditional stewardship approaches 7:

• Non-specific disease presentations make pathogen identification difficult 7
• Limited evidence for definitive treatment durations in many pediatric infections 7
• Fewer pediatric-trained infectious disease physicians available for consultation 7
• Applicability of intensive laboratory testing varies by age and clinical context 7

Most ASP studies exclude PICU and NICU populations, creating knowledge gaps 7. Areas requiring focused attention include appropriate antibiotic initiation, duration, and de-escalation strategies 7.