GUIDELINES FOR TREATMENT OF BACTERIAL IN PEDIATRICS (COMMUNITY- OR INTRAPARTUM-ACQUIRED)

Common Duration of Comments/Reference Pathogens Therapy

0-7 days (<2000 g): Ampicillin 50 mg/kg/dose IV q12h  CT prior to lumbar puncture if: + Cefotaxime 50 mg/kg/dose IV q12h If an organism is o Immunocompromised identified, the o History of CNS disease (mass lesion, 0-7 days (>2000 g): typical duration of stroke) Ampicillin 50 mg/kg/dose IV q8h therapy is: o New onset seizures + Cefotaxime 75 mg/kg/dose IV q12h o Papilledema <1 month* o Abnormal level of consciousness 8 days-30 days (<1200 g): N. meningitides: o Focal neurologic deficit S. agalactiae, Ampicillin 50 mg/kg/dose IV q12h 7 days E. coli, + Cefotaxime 50 mg/kg/dose IV q12h  The use of dexamethasone has L. monocytogenes, H. influenzae: 8 days-30 days (1200-2000 g): demonstrated a decrease in morbidity in Klebsiella spp 7 days Ampicillin 50 mg/kg/day IV q8h children with meningitis due to H. + Cefotaxime 37.5 mg/kg/dose IV q6h S. pneumoniae: influenzae type B and in adults with or 50 mg/kg/dose IV q8h 10-14 days meningitis due to S. pneumoniae. 8-30 days (>2000 g): Dexamethasone may be considered for Ampicillin 50 mg/kg/dose IV q6h or S. agalactiae: pediatric patients with meningitis due to 67 mg/kg/dose IV q8h 14-21 days either H. influenzae or S. pneumoniae. + Cefotaxime 50 mg/kg/dose IV q6h or q8h Aerobic GNRs: 21 days  Dexamethasone should be administered 1 - 2 months 10-20 min before therapy

Cefotaxime 75 mg/kg/dose IV q6h or L. monocytogenes: for maximal efficacy and continued for 2- S. pneumoniae, q8h 21 days 4 days. N. meningitidis, + IV S. agalactiae, H. influenzae  If dexamethasone is utilized for Preferred: meningitis, then rifampin (10-20 Ceftriaxone 50 mg/kg/dose IV q12h mg/kg/day, max 600 mg/day) should also (max: 2 g/dose) be administered. + Vancomycin IV If an organism is identified, the

typical duration  If an organism is identified via CSF Non-life threatening penicillin or 2 months- 18 years of therapy is: culture, then definitive therapy should be cephalosporin allergy: narrowed to a single agent with good CSF N. meningitidis, Meropenem 40 mg/kg/dose q8h N. meningitides: penetration and activity against the S. pneumoniae (max: 2 g/dose) 7 days causative organism.

+ Vancomycin IV

S. pneumoniae:  If history or physical exam findings are Life threatening penicillin allergy: 10-14 days concerning for HSV encephalitis, consider Aztreonam 40 mg/kg/dose q6h the use of acyclovir. (max: 2 g/dose) + Vancomycin IV

Common Duration of Empiric Therapy Comments/Reference Pathogens Therapy Preferred: Ceftriaxone 50 mg/kg/dose IV q12h (max: 2 g/dose) + Vancomycin IV

Basilar skull Non-life threatening fracture PCN/cephalosporin allergy:

Meropenem 40 mg/kg/dose IV q8h S. pneumoniae, (max: 2 g/dose) H. influenzae, + Vancomycin IV Group A strep

Life threatening penicillin allergy: Aztreonam 40 mg/kg/dose IV q6h (max: 2 g/dose)  Patients with significant barrier + Vancomycin IV disruption are at increased risk of resistant-gram negative organisms thus Preferred: requiring broadening of ceftriaxone to Cefepime 50 mg/kg/dose IV q8h cefepime (max: 2 g/dose) Penetrating + Vancomycin IV trauma  Adjust cefepime, vancomycin,

meropenem, and aztreonam in patients Non-life threatening S. aureus, with renal dysfunction PCN/cephalosporin allergy: Coag-negative Meropenem 40 mg/kg/dose IV q8h  CT prior to lumbar puncture if: Staphylococci, 7-21 days (plus) (max: 2 g/dose) o Immunocompromised Aerobic gram- + Vancomycin IV o History of CNS disease (mass lesion, negative bacilli stroke) (including Life threatening penicillin allergy: o New onset seizures Pseudomonas) Aztreonam 40 mg/kg/dose IV q6h o Papilledema (max: 2 g/dose) o Abnormal level of consciousness o + Vancomycin IV Focal neurologic deficit

Preferred:  For infants and children with CSF shunts, Cefepime 50 mg/kg/dose IV q8h vancomycin alone may be appropriate if (max: 2 g/dose) GNRs are not identified on gram-stain Post neurosurgery + Vancomycin IV

Aerobic gram- Non-life threatening negative bacilli PCN/cephalosporin allergy: (including Meropenem 40 mg/kg/dose IV q8h Pseudomonas) (max: 2 g/dose) S. aureus, + Vancomycin IV Coag-negative Staphylococci Life threatening penicillin allergy: Aztreonam 40 mg/kg/dose IV q6h (max: 2 g/dose) + Vancomycin IV

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Common Duration of Empiric Therapy Comments/Reference Pathogens Therapy  CSF shunt : Gold standard for clearance is removal of shunt. Preferred: Prior to replacement of shunt, cultures Cefepime 50 mg/kg/dose IV q8h Presence of CSF should be negative for: (max: 2 g/dose) shunt o Coagulase negative Staphylococci + + Vancomycin IV normal CSF findings: 3 days

Aerobic gram- o Coagulase negative Staphylococci + Non-life threatening negative bacilli abnormal CSF findings: 7 days PCN/cephalosporin allergy: o S. aureus: 10 days (including Meropenem 40 mg/kg/dose IV q8h 7-21 days (plus) o Gram negative bacilli: 10-14 days Pseudomonas), (max: 2 g/dose) (plus) S. aureus, + Vancomycin IV Coag-negative  For infants and children with CSF shunts, Staphylococci, Life threatening penicillin allergy: vancomycin alone may be appropriate if Propionibacterium Aztreonam 40 mg/kg/dose IV q6h GNRs are not identified on gram-stain acnes (max: 2 g/dose)  Adjust cefepime, vancomycin, + Vancomycin IV meropenem, and aztreonam in patients with renal dysfunction *These guidelines are not intended for use in neonatal patients who have been hospitalized beyond the initial postpartum time period.

Reference: Tunkel AR et al. Practice Guidelines for the Management of Bacterial Meningitis. Clin Infect Dis. 2004. 39 (9), 1267-84.

Antimicrobial Subcommittee Approval: N/A Originated: Unknown P&T Approval: 11/2011 Last Revised: 03/2021 Revision History: 03/21: Updated vnacomycin hyperlinks The recommendations in this guide are meant to serve as treatment guidelines for use at Michigan Medicine facilities. If you are an individual experiencing a medical emergency, call 911 immediately. These guidelines should not replace a provider’s professional medical advice based on clinical judgment, or be used in lieu of an Infectious Diseases consultation when necessary. As a result of ongoing research, practice guidelines may from time to time change. The authors of these guidelines have made all attempts to ensure the accuracy based on current information, however, due to ongoing research, users of these guidelines are strongly encouraged to confirm the information contained within them through an independent source.

If obtained from a source other than med.umich.edu/asp, please visit the webpage for the most up-to-date document.

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