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Infection/Condition and Likely Organism |
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Viral (Most common cause) Enteroviruses (Coxsackie and EV71) Adenovirus Influenza HIV |
Treatment mainly supportive. |
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For severe HFMD with cardiopulmonary failure stage, IVIG may be considered |
CARDIOVASCULAR SYSTEM INFECTIONS
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Infection/Condition and Likely Organism |
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Viral (Most common cause) Bacterial: Staphylococcus aureus Haemophilus influenzae Salmonella spp. |
Treatment mainly supportive. Empiric for purulent pericarditis: Cloxacillin 200mg/kg/day IV in 4-6 divided doses PLUS Cefotaxime 200-300mg/ kg/day IV in 4 divided doses |
Penicillin allergy: Cefazolin 100mg/kg/day IV in 3 divided doses (max. 6gm/day) 2nd line Vancomycin 60mg/kg/day IV in 2-3 divided doses (max. 2gm/day) |
Pericardial fluid Gram Stain (G/S) and C&S. Consider surgical drainage for tamponade, pre-tamponade and ineffective conservative management. Duration of therapy: 4 weeks |
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Infection/Condition and Likely Organism |
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Preferred |
Alternative |
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Empirical therapy for infective endocarditis |
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Community-acquired organisms: Streptococcus, Enterococcus HACEK Gram-negative organisms |
Ampicillin 200-300mg/kg/ day in 4-6 divided doses PLUS Gentamicin 3mg/kg q24h |
PLUS* *Cloxacillin 200mg/kg/day IV in 4-6 divided doses |
*For acute presentation, need to cover for MSSA since Streptococcus, Enterococcus, HACEK presentations are usually sub-acute. |
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Healthcare-associated organisms: MRSA Non-HACEK Gram-negative organisms Enterococcus spp. |
Vancomycin 60mg/kg/ day IV in 2-3 divided doses (max. 2gm/day) PLUS Gentamicin 3mg/kg q24h PLUS* Rifampicin 20mg/kg/day in 3 divided doses (max. 900mg/day) |
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*Rifampicin is ONLY for prosthetic valve AND added after 3-5 days after Vancomycin and Gentamicin. If non-HACEK Gram-negative organism like Pseudomonas spp. is suspected, add Cefepime 50mg/kg/dose IV q8h until cultures are known. |
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Infection/Condition and Likely Organism |
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Preferred |
Alternative |
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Infective Endocarditis (Streptococcus viridans) |
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Strains fully susceptible to penicillin (MIC<0.125mg/l) |
Benzylpenicillin 200,000-300,000 units/kg/day IV in 4-6 divided doses (up to 12-18MU/day) |
Ampicillin 300mg/kg/day IV in 4-6 divided doses (max. 12gm/day) OR Ceftriaxone 100mg/kg/ day IV in 1-2 divided doses (max. 4gm/day) OR Penicillin allergy **Vancomycin 40mg/kg/ day IV in 2-3 divided doses (max. 2gm/ day) |
Duration: 4 weeks for native valve 6 weeks for prosthetic valve Vancomycin dose adjusted for trough concentration of 10-15mg/kg. *Vancomycin therapy is recommended only for patients with immediate type penicillin hypersensitivity. For this (MIC>0.125mg/l): Antibiotic of choice is either penicillin with Gentamicin or Ceftriaxone with Gentamicin. |
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Strains with MIC>0.125 mg/l to 2 mg/l |
PLUS Gentamicin 3mg/kg q24h for 2 weeks (add to first line regimen of Penicillin/Ceftriaxone) |
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Infection/Condition and Likely Organism |
Suggested Treatment |
Comments |
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Preferred |
Alternative |
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Infective Endocarditis (Enterococcus spp.) |
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Penicillin-susceptible (MIC≤ 8mg/l) |
Ampicillin 200-300mg/kg/ day IV in 4-6 divided doses for *4-6 weeks PLUS Gentamicin 3mg/kg q24h for *2-6 weeks |
Ampicillin 200-300mg/ kg/day IV in 4-6 equally divided doses PLUS Ceftriaxone 100mg/kg/ day IV in 1-2 divided doses |
*Duration: If symptoms less than 3 months and native valve: Ampicillin for 4 weeks and Gentamicin for 2 weeks. If symptoms more than 3 months: Ampicillin and Gentamicin for 6 weeks. Ampicillin plus Ceftriaxone alone since enterococcus is intrinsically resistant to this drug. This combination is NOT ACTIVE against Enterococcus faecium. **Maximum dose of Vancomycin: 2gm/day unless not able to achieve therapeutic range. Aim for serum trough of 10-20mg/l. |
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Sensitive to penicillin and Vancomycin but high-level resistance to Gentamicin (MIC>500mg/l) |
Ampicillin 300mg/kg/day IV in 4-6 divided doses PLUS Ceftriaxone 100mg/kg/ day IV in 1-2 divided doses (max. 4gm/day) Duration: 6 weeks |
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Resistant to penicillin but susceptible to Vancomycin and Gentamicin |
**Vancomycin 40mg/kg/ day IV in 2-3 divided doses PLUS Gentamicin 3mg/kg q24h Duration: 6 weeks |
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Infection/Condition and Likely Organism |
Suggested Treatment |
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Preferred |
Alternative |
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Infective Endocarditis (Staphylococcus aureus) |
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MSSA (left-sided) |
Cloxacillin 200-300mg/kg/ day IV in 4-6 divided doses for 4-6 weeks |
Penicillin allergy Cefazolin 100mg/kg/day IV in 3 divided doses for 4-6 weeks OR Vancomycin 60mg/kg/day IV in 2-3 divided doses for 4-6 weeks |
If allergy to penicillin but not immediate type hypersensitivity, use Cefazolin. Methicillin-susceptible (right sided): Can shorten duration to 2 weeks if: good response no metastatic sites no cardiac or extracardiac complications size of vegetation less than 20mm. |
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MSSA (right-sided) |
Cloxacillin 200-300mg/kg/ day IV in 4-6 divided doses for 4 weeks |
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MRSA (left and right) |
Vancomycin 60mg/kg/ day IV in 2-3 divided doses (max. 2gm/day) for 4-6 weeks |
Daptomycin 10mg/kg IV daily for 4-6 weeks |
Daptomycin is superior to Vancomycin for MRSA bacteremia with MIC>1mg/l. |
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MSSA (prosthetic valve) |
Cloxacillin 200-300mg/kg/ day IV in 4-6 divided doses for ≥6 weeks PLUS Gentamicin 3mg/kg q24h for 2 weeks PLUS *Rifampicin 20mg/kg/day PO in 3 divided doses for ≥ 6 weeks |
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*Rifampicin has better penetration but to protect against development of resistance, use only after 3-5 days of Cloxacillin and/or bacteremia has been cleared. MRSA (prosthetic valve): Vancomycin * Rifampicin for 6 weeks or more. |
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MRSA (prosthetic valve) |
Vancomycin 60mg/kg/day in 2-3 divided doses ≥ 6 weeks PLUS Gentamicin 3mg/kg q24h for 2 weeks PLUS *Rifampicin 20mg/kg/day PO in 3 divided doses ≥6 weeks |
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Culture-negative endocarditis |
Ampicillin-sulbactam 300mg/kg/day IV in 4-6 divided doses for 4-6 weeks PLUS Gentamicin 3mg/kg q24h for 4-6 weeks |
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Culture-negative endocarditis (CNE) is diagnosed when a child has clinical and echocardiogram evidence of IE but persistent negative cultures. This is in individuals with no prior antimicrobial use. If fungi or fastidious organism is suspected, need to ask microbiologist to prolong incubation. |