SURGICAL INFECTIONS IN CHILDREN

Infection/Condition and Likely Organism

Suggested Treatment

Comments

Preferred Treatment

Alternative Treatment

Empyema thoracis (lung empyema)

Staphylococcus aureus

Streptococcus pneumoniae

Empirical treatment needs to cover organisms mentioned above.

Other bacteria implicated: Streptococcus pyogenes, Haemophilus influenzae and other Gram negative organisms in immunocompromised individuals

If patient is not responding to treatment, need to rule out TB.

Cefuroxime 100-200mg/kg/day IV in 3 divided doses

PLUS

Cloxacillin 200-300mg/ kg/day IV in 4-6 divided doses

Duration: 4-6 weeks

Staphylococcus aureus methicillin-susceptible): Cloxacillin 200-300mg/ kg/day IV in 4-6 divided doses for 4-6 weeks

Streptococcus pneumoniae (penicillin-susceptible): Benzylpenicillin 200,000-300,00units/kg/day IV in 4-6 divided doses

Streptococcus pneumoniae (penicillin-resistant, use result of C&S):

Cefotaxime 200-300mg/ kg/day IV in 4 divided doses

OR

Ceftriaxone 100mg/kg/ day IV in 1-2 divided doses (max. 2gm/dose; 4gm/ day)

Based on C&S of pleural fluid/ tissue or blood culture.

Pneumatocoele on chest X-ray indicate Staphylococcus aureus BUT they can also be seen in pneumococcal disease.

There is NO need for routinely use a macrolide antibiotic but its use should be considered in children whom Mycoplasma pneumoniae is thought to be the cause (Mycoplasma usually causes effusion, not empyema).

Duration: 4-6 weeks total.

Enterocolitis

Enterobacteriaceae,

Enterococci, Bacteroides

Ampicillin 200mg/kg/ day IV in 4-6 divided doses (max. 12gm/day)

PLUS

Metronidazole 15mg/ kg loading dose, followed by 7.5mg/kg/ dose IV q8h

Cefotaxime 200mg/kg/ day IV in 4 divided doses

PLUS

Metronidazole 15mg/kg loading dose, followed by 7.5mg/kg/dose IV q8h

Infection/Condition and Likely Organism

Suggested Treatment

Comments

Preferred Treatment

Alternative Treatment

Septic arthritis (SA) and Osteomyelitis (OM)

Common organisms:

0-2 months old:

Staphylococcus aureus

Streptococcus agalactiae

Gram-negative enteric organism

Less than 5 years old:

Staphylococcus aureus

Streptococcus pyogenes

Streptococcus pneumoniae

Non-typeable Haemophilus spp.

Kingella kingae

Older than 5 years:

Staphylococcus aureus

Streptococcus pyogenes

0-2 months old: Cloxacillin 200mg/kg/ day IV in 4-6 divided doses

PLUS

Cefotaxime 200mg/kg/day IV in 4 divided doses

Empiric antibiotics should be started based on clinical diagnosis of SA or OM.

Surgical debridement often not required in OM.

Urgent wash out and drainage is needed in SA in hip and other joints to reduce pressure on growth plate.

*IV antibiotics can be switched to oral if no concurrent bacteremia when: Child afebrile and pain-free for at least 24 hours and CRP <20mg/L or CRP decreased by ≥2/3 of the highest value.

Duration of antibiotics:

SA: total of 3-4 weeks

OM: 4-6 weeks

In complex disease (multifocal, significant bone destruction, immunocompromised host and resistant/unusual pathogens), prolonged intravenous antibiotics are needed and duration might exceed 6 weeks.

Less than 5 years old:

Cefuroxime 100- 200mg/kg/day IV in 3 divided doses (monotherapy)

Cefazolin 100-150mg/kg/ day IV in 3 divided doses (Can be used in children with suspected Staphylococcus aureus or Streptococcus pyogenes. Less hypersensitivity reaction compared to Cloxacillin and more convenient dosing)

*Kingella kingae:

Uncommon organism causing infection in <5 years old; susceptible to β-lactam antibiotics e.g. Cefuroxime or Amoxicillin-clavulanate.

More than 5 years old: Cloxacillin 200mg/kg/day IV in 4-6 divided doses