1. Antibiotic Choices for Infections which Require Hospitalization Rodolfo E. Bégué, MD Chief, Infectious Diseases Pediatrics, LSUHSC rbegue@lsuhsc.edu

2. Infections which require hospitalization Examples: r/o sepsis meningitis / encephalitis brain abscess / orbital cellulitis pneumonia / endocarditis acute abdomen urinary tract infection bone & joint skin & skin structures

3. Fever  r/o sepsis Hyperthermia or hypothermia Tachycardia Tachypnea Leukocytosis or leukopenia Toxicity = clinical picture - lethargy - hypoperfusion - hypoventilation, hyperventilation or cyanosis.

4. Sepsis work-up Cell Blood Count (CBC)  Blood Culture Urine analysis  Urine Culture Chest roentgenogram Stool NPA Lumbar puncture  CSF Culture (CRP, Procalcitonin)

5. Etiologies of Sepsis < 1 month of age Group B Streptococcus Escherichia coli (Listeria monocytogenes) 1-3 months of age Streptococcus pneumoniae ( ↓ ) Group B Streptococcus Neisseria meningitidis Salmonella spp (Haemophilus influenzae b) (Listeria monocytogenes) 3-36 months of age Streptococcus pneumoniae ( ↓ ) Neisseria meningitidis (Haemophilus influenzae b)

6. Antibiotics for a child with r/o Sepsis Empiric Antibiotic Treatment: 3 months:Cefotaxime (Vancomycin?) x 7-14 days

7. Is it a contaminant? 1 vs >2 positive culture Pathogen vs no pathogen Symptoms vs no symptoms Timing ( 24 h) Plate vs broth (“thio”)

8. Central Line Infection Central & Peripheral Blood Culture Gram-positive, Gram-negative, Fungi If possible, change line (Staph, Enteroc, GN, Fungi, Mycobact) vs treat through line If line out: ~ 1 week If line in: ~ 2 weeks Antibiotic lock

9. Bacterial Meningitis Diagnosis: LP, LP, LP Should I do an LP? Increased intracranial pressure Prior antibiotics “Bloody tap”

10. Bacterial Meningitis: Treatment Neonate:Amp+Gent / Amp+Cefotax Older child:cefotaximeplus vancomycin Modify according to susceptibilities: penicillin cefotaxime vancomycin plus cefotaxime Corticosteroids (?) Rifampin (?)

11. Aseptic Meningitis Viral (enterovirus vs others) “Partially treated” Other causes only on special populations

12. Encephalitis Not bacterial HSV Enterovirus Arbovirus (WNV) EBV, CMV, etc ADEM

13. HSV Encephalitis Acyclovir: 60 mg/kg/d div q 8 hr 750 mg/m 2 /d div q 8 hr x 21 days IV

14. Brain abscess Source: Proximity: middle ear, sinuses Meningitis Hematogenous Penetrating: wound, surgery

15. Brain abscess Triad: Headache Focal neurologic findings Fever Treatment: Surgery Antibiotics: Cefotax + Vanco + (Metro) for 4-8 weeks (IV)

16. Orbital Cellulitis Triad: Proptosis Decreased eye movement Pain on eye movement

17. Orbital Cellulitis Treatment: Antibiotics: Cefotax + Vanco + (Metro) Cefotax + Clinda x 10-14 d IV and 7-14 d PO Surgery (ORL, Ophthalmology)

18. HSV Keratitis Management: With an ophthalmologist antivirals: 1-2% trifluridine 1% iododeoxyuridine 3% vidarabine x 14-21 days topical corticosteroids contraindicated No need for systemic acyclovir

19. Pneumonia Viral: Influenza, RSV Bacterial Streptococcus pneumo Staph aureus Group A Streptococcus TB Chlamydia Mycoplasma Fungal

20. Empiric Treatment for Pneumonia If sick enough to require admission (assuming viral panel negative), the regular r/o sepsis regimen is usually OK: Ampi + genta / Ampi + cefotax / Cefotax Usually add a macrolide (erythro or azithro) Add Vancomycin if VERY sick or necrotizing Others (TB, Gram-negative, PCP, fungal) only if a good reason to suspect

21. Endocarditis Acute  Staph (MRSA) Subacute  viridans Strept Antibiotics: Vanco + gentamicin Penicillin + gentamicin X 2 w, 4-6 w Surgery (?)

22. Pericarditis “Purulent pericarditis” Strept Pneumo Staph aureus (MRSA) Antibiotics: Ceftriaxone + Vancomycin X 4 weeks Surgery (?)

23. Acute Abdomen Diagnosis: Clinical Imaging (XR, US, CT) Treatment Surgery Antibiotics Mild-moderateSevere Ampi/sulb, Ticar/clavPiperac/Tazobactam Imipenem, Meropenem, Ertapenem Cefazolin or cefuroxime + metronidazole Cefotax, ceftriax, ceftaz, cefepime + metronidazole Ampi + genta (Tobra) + Metronidazole (Clinda) Cipro, levoflox, gatiflox + Metronidazole Aztreonam + Metronidazole For 5-7 days IDSA. CID 2010;50:133-64 PO Cipro/Metro or Amox/Clav x 14-21 d

24. Urinary Tract Infection Always suspect in febrile children < 2 yrs of age Dx of UTI requires a UCx (bag-specimen not good) UA (WBC), dipstick OK as a guide, especially in combination Gram stain (“unspun” urine) Etiology Escherichia coli Enterococcus

25. Urinary Tract Infection Follow-up US, VCUG DMSA scan Consider prophylaxis Inpatient Treatment Cefotaxime or Ceftriaxone Ampicillin + gentamicin

26. Osteomyelitis Staph aureus (Others in especial populations) Clindamycin Vancomycin Linezolid X 4 weeks (IV/PO) Surgery

27. Septic arthritis Fever, joint pain/swelling, decreased ROM Diagnosis: clinical, XR (hip), US, arthrocentesis, CT (SI)

28. Septic arthritis Treatment: Aspirate vs Surgery: hips, shoulders Antibiotics: Vancomycin (Clinda, Oxacillin) + cefotaxime (cefuroxime) x 3 weeks (IV/PO) Etiologies: Staph aureus Streptococcus (GAS, Strept pneumo) Kingella kingae Salmonella Neisseria (GC, N. meningitidis) (H. influenzae)

29. Puncture wounds (foot) Etiology Staph aureus (~ 3 d) Pseudom spp (~ 7 d) Mycobacteria (~ 2-4 w) Treatment Wound care Tetanus vaccine Anti-Staph antibiotics If no response Surgical exploration → culture Ceftazidime → ciprofloxacin (for 2 w)

30. Skin and Soft Tissue Etiology: Group A Streptococcus Staphylococcus aureus (MRSA) (Strep pneumo / Hib) Treatment: Vancomycin or Clindamycin add rifampin? linezolid?? Drain any abscess

31. Any Question?