Antibiotic Choices for Infections which Require Hospitalization Rodolfo E. Bégué, MD Chief,...
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Transcript of Antibiotic Choices for Infections which Require Hospitalization Rodolfo E. Bégué, MD Chief,...
Antibiotic Choices for Infections which Require Hospitalization
Rodolfo E. Bégué, MD
Chief, Infectious Diseases
Pediatrics, LSUHSC
Infections which require hospitalization
Examples:r/o sepsismeningitis / encephalitisbrain abscess / orbital cellulitispneumonia / endocarditisacute abdomenurinary tract infection bone & jointskin & skin structures
Fever r/o sepsis
• Hyperthermia or hypothermia
• Tachycardia
• Tachypnea
• Leukocytosis or leukopenia
• Toxicity = clinical picture - lethargy - hypoperfusion - hypoventilation, hyperventilation or cyanosis.
Sepsis work-up
• Cell Blood Count (CBC) Blood Culture
• Urine analysis Urine Culture
• Chest roentgenogram
• Stool
• NPA
• Lumbar puncture CSF Culture
• (CRP, Procalcitonin)
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)
Antibiotics for a child with r/o Sepsis
Empiric Antibiotic Treatment:< 1 month: Ampicillin + Gentamicin
Ampicillin + Cefotaxime
1-3 months: Ampicillin + Cefotaxime
> 3 months: Cefotaxime
(Vancomycin?)
x 7-14 days
Is it a contaminant?
• 1 vs >2 positive culture
• Pathogen vs no pathogen
• Symptoms vs no symptoms
• Timing (< 24 h vs > 24 h)
• Plate vs broth (“thio”)
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 weekIf line in: ~ 2 weeks
• Antibiotic lock
Bacterial Meningitis
• Diagnosis: LP, LP, LP
• Should I do an LP?
• Increased intracranial pressure
• Prior antibiotics
• “Bloody tap”
Bacterial Meningitis: Treatment
• Neonate: Amp+Gent / Amp+Cefotax
• Older child: cefotaxime plus vancomycin
• Modify according to susceptibilities:penicillincefotaximevancomycin plus cefotaxime
• Corticosteroids (?)
• Rifampin (?)
Aseptic Meningitis
• Viral (enterovirus vs others)
• “Partially treated”
• Other causes only on special populations
Encephalitis
• Not bacterial
• HSV Enterovirus Arbovirus (WNV) EBV, CMV, etc
• ADEM
HSV Encephalitis
Acyclovir:
60 mg/kg/d div q 8 hr
750 mg/m2/d div q 8 hr
x 21 days IV
Brain abscess
Source:
• Proximity: middle ear, sinuses
• Meningitis
• Hematogenous
• Penetrating: wound, surgery
Brain abscess
Triad:
• Headache
• Focal neurologic findings
• Fever
Treatment:
• Surgery
• Antibiotics: Cefotax + Vanco + (Metro)
• for 4-8 weeks (IV)
Orbital Cellulitis
Triad:
• Proptosis
• Decreased eye movement
• Pain on eye movement
Orbital Cellulitis
Treatment:
• Antibiotics:Cefotax + Vanco + (Metro) Cefotax + Clindax 10-14 d IV and 7-14 d PO
• Surgery (ORL, Ophthalmology)
HSV Keratitis
Management:
• With an ophthalmologist
• antivirals:1-2% trifluridine1% iododeoxyuridine3% vidarabinex 14-21 days
• topical corticosteroids contraindicated
• No need for systemic acyclovir
Pneumonia
• Viral:Influenza, RSV
• BacterialStreptococcus pneumoStaph aureusGroup A Streptococcus
• TB
• ChlamydiaMycoplasma
• Fungal
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
Endocarditis
• Acute Staph (MRSA)
• Subacute viridans Strept
• Antibiotics: Vanco + gentamicin Penicillin + gentamicin
• X 2 w, 4-6 w
• Surgery (?)
Pericarditis
• “Purulent pericarditis”
• Strept PneumoStaph aureus (MRSA)
• Antibiotics: Ceftriaxone + Vancomycin
• X 4 weeks
• Surgery (?)
Acute AbdomenDiagnosis:
• Clinical
• Imaging (XR, US, CT)
Treatment
• Surgery
• Antibiotics
Mild-moderate Severe
Ampi/sulb, Ticar/clav Piperac/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
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
Urinary Tract Infection
Follow-up
• US, VCUG
• DMSA scan
• Consider prophylaxis
Inpatient Treatment
• Cefotaxime or Ceftriaxone
• Ampicillin + gentamicin
Osteomyelitis
• Staph aureus
• (Others in especial populations)
• ClindamycinVancomycinLinezolid
• X 4 weeks (IV/PO)
• Surgery
Septic arthritis
• Fever, joint pain/swelling, decreased ROM
• Diagnosis: clinical, XR (hip), US, arthrocentesis, CT (SI)
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 kingaeSalmonella
• Neisseria (GC, N. meningitidis)
• (H. influenzae)
Puncture wounds (foot)
Etiology
• Staph aureus (~ 3 d)
• Pseudom spp (~ 7 d)
• Mycobacteria (~ 2-4 w)
Treatment
• Wound careTetanus vaccineAnti-Staph antibiotics
• If no responseSurgical exploration → cultureCeftazidime → ciprofloxacin (for 2 w)
Skin and Soft Tissue
• Etiology:Group A Streptococcus Staphylococcus aureus (MRSA)(Strep pneumo / Hib)
• Treatment:Vancomycin or Clindamycinadd rifampin?linezolid??
• Drain any abscess
Any Question?