Empiric Treatment of Suspected Infection in Pediatric Patients with End-Stage Liver Disease/Biliary Atresia Applies to pre-transplant pediatric patients with known liver disease primarily at risk for infection with enteric organisms

Pediatric Hepatology service should be Initial Evaluation: Initial evaluation should determine consulted if not already aware of patient Obtain cultures before antibiotics when likelihood of ascending cholangitis, vs. possible spontaneous bacterial peritonitis (SBP), vs. other community- or hospital-onset Physical examination infectious source. See separate algorithm for Blood culture - all CVC lumens + peripheral neonatal and pediatric patients U/A + urine culture Ascending cholangitis should be with suspected infection at AST, ALT, total & direct bilirubin, GGT, suspected with fever and an increase in initial evaluation for alkaline phosphatase bilirubin from baseline acute liver failure If respiratory signs/symptoms: SBP should be suspected in a patient See separate algorithm for Endotracheal aspirate if intubated with ascites who has fever and suspected hospital-onset Chest X-ray abdominal pain/tenderness infection in patients with acute Consider respiratory virus testing liver failure or early If the patient is clinically stable and an post-transplantation If ascites: Paracentesis if able obvious focal source is identified on exam (e.g. acute otitis media, URI), not Avoid culturing long term biliary drains all of the recommended evaluation may be needed. Use clinical judgement.

Continue evaluation for ascending Alternative infectious Clear focal source identified - cholangitis, SBP, or other serious NO source identified from YES stable patient with low concern for bacterial infection initial assessment? ascending cholangitis or SBP

Start Piperacillin-tazobactam* ID consult recommended at this ADD Vancomycin if patient has central stage if patient has severe venous catheter or findings of soft tissue sepsis/septic shock or has history Target antibiotics to infection of multi-drug resistant organism(s) identified source - follow Pediatric Guidelines at Follow Pediatric Dosing Guideline *Consult ID or Antimicrobial idmp.ucsf.edu Stewardship Program for empiric Modify therapy as needed if patient has therapy recommendation if patient prior history of multi-drug resistant has severe beta lactam allergy organism(s)

ID consult recommended Stable/Improving NO Repeat cultures before at 48 hours*? *For unexplained deterioriation on modifying therapy initial therapy before 48 hours, modification of therapy may be YES indicated - ID consult is recommended

Infectious source NO Stop antibiotics identified? These are guidelines only and cannot be applied to every situation. They reflect consensus of the UCSF Pediatric Liver YES Transplant Program and Pediatric Antimicrobial Stewardship Program based on available evidence and hospital antibiogram data. Target antibiotics to identified source - follow UCSF Pharmacy & Therapeutics Committee Approved Pediatric Guidelines at 08/31/2018; Content Owner: Rachel Wattier, MD, MHS, idmp.ucsf.edu Pediatric Antimicrobial Stewardship Program