CONNECTICUT CHILDREN’S MEDICAL CENTER’S Clinical Pearls Some Common Age Specific Questions: • Bactrim/ceftriaxone: generally not recommended for patients ≤ 2 mos Antimicrobial Stewardship Program due to risk of developing kernicterus PAID The following reconstituted suspensions require NONPROFIT

U.S. POSTAGE •

HARTFORD, CT refrigeration: Augmentin, Cefpodoxime, Cefprozil, Cefuroxime, Doxycycline generally not recommended for patients ≤ 8 yo as it may PERMIT NO. 3745 Cephalexin, Erythromycin (some forms), and Penicillin cause permanent teeth staining in young children • Fluoroquinolones: generally not recommended as first line therapy Empiric Outpatient The following reconstituted suspensions due to the risk of tendonitis/tendon rupture; (if used) must document should NOT be refrigerated: counseling Antimicrobial Guide Cefdinir, Clindamycin and Voriconazole • Nitrofurantoin: generally not recommended for patients ≤ 1 mos due to risk of developing hemolytic anemia Stability of Commonly reconstituted Suspensions Some Common Considerations in Selection of Therapy: For questions please contact: 10 DAYS 14 DAYS • Nitrofurantoin: generally not recommended for treatment of UTIs in infants Antimicrobial Stewardship Augmentin Amoxicillin and young children because renal involvement is likely and the drug only concentrates in urine Co-Directors: Azithromycin Cefpodoxime Jennifer Girotto, PharmD & Cefdinir Cephalexin • Oseltamivir: Cefuroxime Ciprofloxacin - Should be considered in all patients that are at high risk for influenza Nicholas Bennett MA(Cantab), MBBChir, PhD Clindamycin complications including those that are < 2 yrs at: [email protected] Doxycycline • High risk includes, immunosuppression, chronic pulmonary, monohydrate cardiovascular, renal, hepatic, hematological and metabolic disorders. Fluconazole - Outpatient use of oseltamivir should begin within 48 hours of when Special thanks to: influenza symptoms began Kathryn Steckowych, PharmD, Penicillin Heather Magsarili PharmD, Kristopher Teti MD, Voriconazole • Fluconazole: exhibits dose dependent inhibition of cytochrome P450 enzymes (CYP); there is potential for significant drug interactions Carolyn Vitale MD, & Paula Lucuara MD Common suspensions that should be taken with food: • Griseofulvin: cross sensitivity with penicillin, use only with caution in Augmentin, Cefuroxime, Doxycycline, Nitrofurantoin, Terbinafine (granules) patients with significant penicillin allergy G-tube considerations: Common medications that should be taken on an empty • Ciprofloxacin: - Suspension should NOT be administered through a feeding tube, stomach: (1 hour before or 2 hours after a meal) Bactrim, Cephalexin, as it will clog it. Instead crush immediate release tablets and dissolve Levofloxacin solution, Metronidazole, Penicillin in water; hold tube feedings for 1 hour before & 2 hours after administration Milk and antacid considerations: (space by 2 hours) Azithromycin, Cefdinir, Ciprofloxacin, Doxycycline, Rounding the dose: Levofloxacin • Rounded dose of oral antibiotic should ideally be within 10-15% of calculated dose Special food considerations: • Suspensions (unless individually stated otherwise) may be mixed with • When calculating a dose based on mg/kg, when reasonable, food such as applesauce or mixed with chocolate syrup and consumed suspensions are easiest to administer if rounded to half or full immediately teaspoonful and tablets can usually be given as full or half tablets. • Griseofulvin • If you are uncertain about rounding, or if a tablet maybe split, ask a - Ultramicrosize tablets may be crushed and sprinkled in applesauce pharmacist.

- Administer w/ fatty meal to increase absorption • For suspensions, accurate measuring devices, such as syringes, can be • Terbinafine granules may be sprinkled in non-acidic foods provided by the pharmacy to assist patients. Principles of antimicrobial stewardship • Optimize antimicrobial therapy to reduce adverse drug reactions and to All content posted on this card is for informational and/or educational limit the development of antibiotic resistance. purposes only. Connecticut Children’s will make all efforts to ensure

Connecticut Children’s Medical Center Street 282 Washington 06106Hartford, CT • Improve patient safety and morbidity/mortality by utilizing correct the accuracy of the content posted on the card. However, Connecticut Children’s makes no guarantee of any kind as to the accuracy or prescribing practices. completeness of the information. Connecticut Children’s will attempt to correct any errors or omissions brought to its attention and to keep the card up to date. Card Last Updated January 2016; approved by P&T February 2016 Skin & Bones Upper Airways & Lungs Influenza Genital Herpes Oseltamivir PO $$$$ First occurrence: Animal Bites Acute Otitis Media/Sinusitis 0-8 mos: 6 mg/kg/day ÷ q12h Valacyclovir PO 40 mg/kg/day ÷ q12h (max 2000 mg/day) $$➞$$$ Augmentin ES PO 90 mg/kg/day ÷ q12h (max 1 gm/dose) $$ Amoxicillin PO 90 mg/kg/day ÷ q8-12h (max 1 gm/dose) $$ 9-23 mos: 7 mg/kg/day ÷ q12h OR Acyclovir PO (suspension: $$$➞$$$$; tablet: $) OR Clindamycin PO 30 mg/kg/day ÷ q8h (max 600 mg/dose) $$$ OR Augmentin ES PO 90 mg/kg/day ÷ q8-12h (max 1 gm/dose) $$ ≤ 15 kg: 30 mg/dose every 12 hours < 12 yo: 40-80 mg/kg/day ÷ q6-8h (max 1000 mg/day) > 15 to 23 kg: 45 mg/dose every 12 hours AND Bactrim PO 8-12 mg/kg/day TMP÷q12h (max 160mgTMP/dose)$ OR > 45 kg Augmentin XR PO 2 gm q12h $$$$ ≥ 12 yo: 400 mg 3 (mes daily or 200 mg 5 (mes daily OR amoxicillin allergy, but tolerate cephalosporins > 23 to 40 kg: 60 mg/dose every 12 hours Duration: 7-10 days Duration: 5 – 10 days > 40 kg: 75 mg/dose every 12 hours cefdinir PO 14 mg/kg/day ÷ q12-24h (max 600 mg/DAY) $$ Suppressive therapy: Duration: 5 days Lyme Disease Duration: 10 days Valacyclovir PO $$$➞$$$$ < 8 yo: Amoxicillin PO 50 mg/kg/day ÷ q8h (max 500mg/dose) $➞$$ Community Acquired Pneumonia Pertussis < 12 yo: some people will use 10-20 mg/kg q24h off label OR if Amoxicillin allergy, but able to take cephalosporins, > 12 yo: 500 mg or 1000 mg q24h (depending on # of recurrences) Amoxicillin PO 90 mg/kg/day ÷ q8h (max 1 gm/dose) $$ Azithromycin PO $ cefuroxime PO 30 mg/kg q12h (max 500 mg/dose) $$$$ 0-5 months: 10 mg/kg/day OR Acyclovir PO 40-50 mg/kg/day ÷ q12h (max 800 mg/day) $$$$ 8 yo: Doxycycline PO 4 mg/kg/day ÷ q12h (max 100 mg/ dose) OR Augmentin ES PO 90 mg/kg/day ÷ q8h (max 1 gm/dose) $$ ≥ ≥6 months: 10 mg/kg/dose (max 500 mg) on day 1, ➞ OR Cefdinir PO 14 mg/kg/day ÷ q12h (max 300 mg/dose) $$ Pelvic Inflammatory Disease (adolescents) $$$ $$$$ followed by 5 mg/kg once daily on days 2-5 (max 250 mg/dose) OR Clindamycin PO 40 mg/kg/day ÷ q8h (max 600 mg/dose) $$$$ Ceftriaxone IM 250 mg as a single dose $ Duration: 14-21 (EM) 28 days (arthritis) OR If unable to take macrolides and > 2 months old, Bactrim OR high-risk & beta-lactam allergic Levofloxacin PO $$$➞$$$$ AND doxycycline PO 100 mg ÷ q12h x 14 days $$ PO 8 mg/kg/day of TMP ÷ q12h (max 160mg/dose TMP) $ Tinea Capitis (head) > 6 mos: 20 mg/kg/day ÷ q12h AND metronidazole PO 500 mg ÷ q12h x 14 days $➞$$ Duration: 5 days (azithromycin) 14 days (Bactrim) Terbinafine granules PO (>/= 4 yo) $$$$ > 5 yo: 14 mg/kg/day ÷ q12h < 25 kg: 125 mg once daily > 10 yo: 10 mg/kg/day ÷ q24h Thrush Trichomoniasis Metronidazole $➞$$ PO 25-35 kg: 187.5 mg once daily Duration: 7 - 10 days Topical: Nystatin PO suspension $ < 45 kg:15 mg/kg/day ÷ q8h x 7 days (max 2000 mg/day) > 35 kg: 250 mg once daily Infants: 200,000 units 4 times daily OR Griseofulvin PO (>/= 2 yo) $$$$ GAS Pharyngitis ≥ 45 kg: 2 g as a single dose Amoxicillin PO 50 mg/kg/day ÷ q12-24h (max 1 gm/day) $ Children: 400,000 to 600,000 units 4 times daily Microsize 20-25 mg/kg once daily (max 1000 mg/dose) OR Penicillin VK PO Children: 250 mg/dose q8-12h $ Systemic: Fluconazole PO 6 mg/kg/dose as a load, then 3 mg/kg/day OR Ultramicrosize 10-15 mg/kg once daily (max 750 mg/dose) Adolescents: 500 mg/dose q12h $ (max 600 mg/day) $$ Specific Recommendations Duration: 6 wks (terbinafine) 6-12 wks (griseofulvin) OR Penicillin G IM Children (<27kg): 600,000 units once Duration: 14 days (fluconazole) *Providers are encouraged to use the narrowest spectrum antibiotic possible OR Cephalexin PO 40 mg/kg/day ÷ q12h (max 500 mg/dose) $$ when treating uncomplicated otitis media, UTIs, pneumonias or other simple Tinea Coporis (Skin) infections OR if beta-lactam allergic Azithromycin PO 12 mg/kg/day Topical clotrimazole (> 3 yo) apply twice daily $ ➞$$ *Providers are encouraged to consider obtaining cultures and narrowing OR Terbinafine granules PO (only if ≥ 4 yo) $$ once daily (max 500 mg/dose) $$ antibiotics based upon culture results < 25 kg: 125 mg once daily Duration: 10 days, except azithromycin is 5 days GI & GU *In well appearing children with fever, consider “wait to use” prescription to 25-35 kg: 187.5 mg once daily discourage unnecessary antibiotic therapy > 35 kg: 250 mg once daily *Providers are encouraged to contact the department with questions about anti- Urinary Tract Infections microbial stewardship OR Fluconazole $$ PO 6 mg/kg once weekly Cephalexin PO 25-50 mg/kg/day ÷ q6-8h (max 1-2 gm/day) $$➞$$$ Duration: 4 wks (clotrimazole), 1 wk (terbinafine), 2-4 wks (fluconazole) OR Cefixime PO 8 mg/kg ÷ q12-24h (max 400 mg/day) $$$$ Non-purulent Cellulitis OR Nitrofurantoin PO 5-7 mg/kg/day ÷ q6h (max 400 mg/day) $$$$ Duration: 7-14 days Cephalexin PO 25-50 mg/kg ÷ q6h (max 500 mg/dose) $$ ABOUT CONNECTICUT CHILDREN’S MEDICAL CENTER (may consider shorter course of at least 5 days in uncomplicated cystitis OR Clindamycin PO 30-40 mg/kg ÷ q8h (max 600 mg dose) Connecticut Children’s Medical Center is the only hospital in Connecticut in girls >2 years and boys between 2 and 13 years) dedicated exclusively to the care of children. Connecticut Children’s is a ➞ $$$ $$$$ nationally recognized, not-for-profit with a medical staff of nearly 1,100 Duration: 5 – 10 days Clostridium difficile Colitis providing comprehensive, world-class health care in more than 20 pediatric Metronidazole PO 30mg/kg/day ÷ q6h (max 1500mg/day) $➞$$ specialties and subspecialties. Connecticut Children’s Medical Center is the Purulent Cellulitis with I&D Duration: 10-14 days primary pediatric teaching hospital for the UConn School of Medicine and Clindamycin PO 30-40 mg/kg/day÷q8h (max 600 mg/dose) Frank H. Netter MD School of Medicine at Quinnipiac University as well as $$$➞$$$$ Bacterial Vaginosis a research partner of Jackson Laboratory. Connecticut Children’s Office for OR Cephalexin PO 25-50 mg/kg/day ÷ q6h (max 500mg/dose) $$ Metronidazole PO 15 mg/kg/day ÷ q12h (max 1000 mg/day) $➞$$ Community Child Health is a national leader in community-based prevention AND Bactrim PO 8-12 mg/kg/day TMP ÷ q12h (max Duration: 7 days and wellness programs. 160mgTMP/dose) $ To learn more about Connecticut Children’s Medical Center, Chlamydia/Gonorrhea please visit connecticutchildrens.org. Duration: 5- 10 days Ceftiriaxone $ IM 250 mg as single dose Abscess AND Doxycycline PO 4 mg/kg/day ÷q12h (max 200 mg/day) Clindamycin PO 40 mg/kg/day ÷ q8h (max 600 mg/dose) $$$➞$$$$ for 7 days $$ OR Azithromycin PO 20 mg/kg (max 1 gram) as a single dose $ Duration: 5 – 10 days *Please note: pricing above is based Pricing Reference on a 20 kg child (when appropriate) $ 0 to 30 dollars and is an average of the cash prices $$ 31 to 100 dollars available at 2 retail pharmacies in CT as

$$$ 101 to 200 dollars of November 2014 (prices are only an 282 Washington Street, Hartford, CT 06106 $$$$ 201+ dollars estimate and are subject to change) © 2017 Connecticut Children’s Medical Center. All rights reserved. 16-115 Rev. 1-17