What are the adjunct therapies to consider for infection management in the pediatric population?

Adjunct Therapies for Pediatric Infection Management

Supportive Care and Symptom Management

Antipyretic therapy with acetaminophen is the first-line adjunct for fever management in pediatric infections, given its superior safety profile compared to other antipyretics. 1

Fever and Pain Control

• Acetaminophen is the safest medication for antipyresis in children and should be considered first-line therapy for fever and pain associated with infections such as otitis media, pharyngitis, and respiratory tract infections. 1

• Ibuprofen suspension should be considered as second-line antipyretic therapy when acetaminophen fails to provide adequate symptom relief, with the advantage of less frequent dosing (every 6-8 hours versus every 4 hours for acetaminophen). 2

• Ibuprofen has been shown to be at least as effective as acetaminophen as an analgesic and more effective as an antipyretic in comparative trials, though both have comparable safety profiles when used appropriately. 2

• Aspirin should be avoided in children with viral illnesses due to the association with Reye's syndrome. 1

Dosing Considerations

• Acetaminophen dosing must account for differences in age, weight, metabolism, and risk of adverse effects in pediatric patients. 3

• Combination therapy with acetaminophen and aspirin may be considered only if the patient fails to respond to other therapies, though this increases the risk of drug toxicity and adverse reactions. 1

Fluid Resuscitation and Nutritional Support

For neonates with necrotizing enterocolitis, fluid resuscitation is a critical adjunct therapy that must be initiated alongside broad-spectrum antibiotics and bowel decompression. 4

• Fluid resuscitation is essential in managing severe pediatric infections, particularly in conditions like necrotizing enterocolitis where hemodynamic stability is compromised. 4

Corticosteroids as Adjunctive Therapy

Adjunctive treatment with corticosteroids is indicated for children with CNS tuberculosis disease and should be strongly considered in specific severe presentations. 4

Tuberculosis-Specific Indications

• Corticosteroids are definitively indicated for children with tuberculous meningitis to reduce inflammation and improve outcomes. 4

• Corticosteroids can be considered for children with pleural or pericardial effusions, severe miliary disease, and significant endobronchial disease related to tuberculosis. 4

Pyridoxine Supplementation

Pyridoxine (vitamin B6) should be administered if isoniazid or cycloserine is used in the treatment of tuberculosis to prevent peripheral neuropathy. 4

• This supplementation is particularly important in malnourished children or those at higher risk for neuropathy. 4

Source Control and Surgical Interventions

Urgent or emergent operative intervention is a critical adjunct for necrotizing enterocolitis when there is evidence of bowel perforation, consisting of either laparotomy or percutaneous drainage. 4

Intra-abdominal Infections

• Intraoperative Gram stains and cultures should be obtained during surgical intervention for necrotizing enterocolitis to guide antimicrobial therapy. 4

• For complicated intra-abdominal infections, source control through drainage or surgical intervention is essential and should be performed alongside antibiotic therapy. 4

Monitoring and Laboratory Support

Antibiotic serum concentrations and renal function should be monitored when using aminoglycosides (gentamicin, tobramycin, amikacin) or vancomycin in pediatric patients. 4

• This monitoring is critical to prevent nephrotoxicity and ototoxicity while ensuring therapeutic drug levels. 4

Directly Observed Therapy (DOT)

Directly observed therapy should be standard of care for children with tuberculosis to ensure medication adherence and optimize treatment outcomes. 4

• DOT is particularly important given the long duration of tuberculosis treatment and the risk of developing drug resistance with incomplete therapy. 4

Important Clinical Caveats

• β-Lactam antibiotic dosages should be maximized if undrained intra-abdominal abscesses may be present to achieve adequate tissue penetration. 4

• For children with severe immunosuppression (CD4 <15% or children ≥6 years old with <100 cells/μL), twice-weekly antimicrobial regimens should not be used as they may lead to rifamycin resistance. 4

• Potential drug interactions should be carefully reviewed when managing pediatric infections, particularly when combining antimicrobials with antiretroviral therapy in HIV-infected children. 4