Paediatric Infections (Neonates, Infants and Children)

Objectives

Treatment for infections in children are included throughout the guideline.

See relevant sections.

Antibiotic dosing principles in Paediatrics

Children >12 years old may receive adult doses
Take special care in neonates as dosages and intervals may differ from older children
The dose must not exceed the maximum adult dose unless specified.
All intravenous infusions should be given carefully according to Injectable Guidelines to avoid thrombophlebitis.

Well baby with obstetric risk factors for infection

Early infections present in the first 3 days after birth and are often associated with obstetric risk factors for infection. Symptoms of neonatal sepsis may be non-specific, and onset may be gradual. Antibiotics are given empirically to babies born to mothers with obstetric risk factors for infection to prevent complications of early onset neonatal sepsis.

Antimicrobial

Ampicillin 50mg/kg IV BID

PLUS

Gentamicin 5mg/kg IV OD (<2kg 48 hourly)

Comments and Duration of Therapy

Obstetric risk factors for early onset neonatal sepsis include:

Home birth
Rupture of membranes >18 hours
Offensive liquor
Preterm delivery
Maternal fever or sepsis
Maternal history of a previous neonatal death from sepsis.

Duration:

Treat for 2 to 5 days

Early and late onset neonatal sepsis

This may present with fever without focus, or more obvious signs of septicaemia. The antibiotics suggested are appropriate for these presentations as well as for pneumonia or urinary tract infection in the neonatal period. The most common infecting organisms include Escherichia coli, Klebsiella pneumoniae, Haemophilus influenzae, Streptococcus aureus, Group B Streptococcus and rarely. Listeria monocytogenes.

Antimicrobial

Early onset sepsis (postnatal age ≤7 days):

Ampicillin 50mg/kg IV BID

PLUS

Amikacin 15mg/kg IV OD

Late onset sepsis (postnatal age >7 days):

Ampicillin 50mg/kg IV TID

PLUS

Amikacin 15mg/kg IV OD

For premature neonates see Neonatal dosing section

Alternative:

If amikacin is not available replace this in above regimes with:

Gentamicin 5mg/kg IV OD (<2kg 48 hourly)

Cefotaxime 50mg/kg IV TID

Ceftriaxone 50mg/kg IV BID (if cefotaxime not available)

If there is no improvement, especially in hospital acquired infection, and there are no microbiology results to direct treatment, ensure blood cultures are taken and consider changing to:

Meropenem 40mg/kg IV TID

PLUS

Vancomycin 15mg/kg IV TID

Comments and Duration of Therapy

Take blood cultures prior to antibiotics. Send urine, CSF, and pus for culture if clinically indicated.

Administer antibiotics within one hour of presentation.

See Neonatal Sepsis Standard Operating Procedure guideline, for further guidance on investigation and management.

Duration:

Change antibiotics according to microbiology results. Treat for 7-10 days

Neonatal sepsis with possible Staphylococcus aureus infection

Suspect Staphylococcus aureus in the setting of:

Fever and skin pustules
Skin abscess
Omphalitis
Pneumonia with pneumatocoele or empyema
Hospital-acquired late onset infection

Antimicrobial

Cloxacillin 50mg/kg IV BID in first week of life, TID after first week of life, QID >21 days.

PLUS

Amikacin 15mg/kg IV BID

For premature neonates see Neonatal dosing section

Alternative:

If amikacin is not available replace this in above regimes with:

Gentamicin 5mg/kg IV OD (<2kg 48 hourly)

Cefotaxime 50mg/kg IV TID in first week of life, QID after first week of life.

Ceftriaxone 50mg/kg IV BID (if cefotaxime not available)

If there is no improvement, especially in hospital acquired infection, and there are no microbiology results to direct treatment, ensure blood cultures are taken and consider changing to:

Meropenem 40mg/kg IV TID

PLUS

Vancomycin 15mg/kg IV BID in in first week of life, TID after first week of life.

Comments and Duration of Therapy

Take blood cultures prior to antibiotics. Administer antibiotics within one hour of presentation.

Abscesses may require incision and drainage. Send pus and wound swabs for culture. Umbilical cord should be cleaned with antiseptic solution and allowed to dry. With omphalitis, consider neonatal Tetanus.

Duration:

Change antibiotics according to microbiology results. Treat for 7-10 days

Neonatal Meningitis

Meningitis in the neonatal period is most commonly caused by Group B Streptococcus, Listeria monocytogenes, and Gram-negative organisms.

Antimicrobial

Ampicillin 100mg/kg IV BID in in first week of life, TID after first week of life.

PLUS

Cefotaxime 50mg/kg IV TID in first week of life, QID after first week of life

PLUS

Amikacin 15mg/kg IV OD for 72 hours.

For premature neonates see Neonatal dosing section

Alternative:

If amikacin is not available replace this in above regimes with:

Gentamicin 5mg/kg IV OD (<2kg 48 hourly)

If cefotaxime is not available replace this in above regime with:

Ceftriaxone 50mg/kg IV BID

In neonates who have been hospitalized since birth and develop meningitis after 7 days replace Ampicillin in the above regime with:

Vancomycin 15mg/kg IV TID

If there is no improvement, especially in hospital acquired infection, and there are no microbiology results to direct treatment, ensure blood cultures are taken and consider changing to:

Meropenem 40mg/kg IV TID

PLUS

Vancomycin 15mg/kg IV BID in in first week of life, TID after first week of life.

Comments and Duration of Therapy

Send blood cultures prior to antibiotics. Send CSF for protein, glucose, cell count, culture and susceptibilities and PCR.

Duration:

Change antibiotics according to microbiology results. Treat for at least a minimum total of 10 days up to 21 days in severe cases, especially in Gram-negative meningitis.

Necrotising Enterocolitis

This infection is common in extremely premature babies, and presents with distended abdomen, feed intolerance, fever, abnormal white cell count and thrombocytopaenia. It is associated with high rates of mortality. Antibiotics target enteric organisms including Gram-positive, Gram-negative, and anaerobic pathogens.

Antimicrobial

Ampicillin 50mg/kg IV BID in in first week of life, TID after first week of life.

PLUS

Amikacin 15mg/kg IV OD

PLUS

Metronidazole 7.5mg/kg IV TID (<2kg BID)

For premature neonates see Neonatal dosing section

If there is no improvement, and there are no microbiology results to direct treatment, ensure blood cultures are taken and consider changing to:

Meropenem 40mg/kg IV TID

PLUS

Vancomycin 15mg/kg IV BID in in first week of life, TID after first week of life.

Comments and Duration of Therapy

Send blood cultures prior to antibiotics.

Duration:

Treat for 7-10 days

Skin pustules (without systemic symptoms) in neonate

Skin infections in neonates are usually caused by Staphylococcus aureus. If fever or other systemic symptoms are present, the infant should be treated with high-dose intravenous antibiotics to cover for the possibility of sepsis.

Antimicrobial

Cloxacillin 25mg/kg PO/IV BID in first week of life, TID after first week of life.

Comments and Duration of Therapy

Wash skin with soap and water, dry and clean with antiseptic solution. Rupture and drainage of pustules is not usually required.

Duration:

Treat for 5-7 days.

Neonatal Malaria

See Timor-Leste National Malaria Guidelines.

Antimicrobial

Artesunate 3mg/kg IV/IM doses at 0, 12 and 24 hours then once daily

Alternative:

Quinine 20mg/kg in 10ml/kg of IV fluid infused of 4 hours. Then 8 hours after initial dose give 10mg/kg in IV fluid over 2 hours, and repeat TDS for total of 7 days.

Neonatal Gonorrhoea prophylaxis

If the mother is successfully treated prior to delivery, no prophylaxis is required for the neonate. If the mother has not been treated, the risk of vertical transmission is 30-40%. A single dose of ceftriaxone provides effective prophylaxis for the neonate.

Antimicrobial

Ceftriaxone 50mg/kg IV/IM single dose.

Comments and Duration of Therapy

For all cases also treat mother and sexual partner. See Gonorrhoea in Genital Infections.

Monitor for active infection and if this occurs see Neonatal Conjunctivitis or Gonococcal Ophthalmia Neonatorum in Paediatric Infections (Neonates, Infants and Children).

Neonatal Chlamydia prophylaxis

If a mother has active Chlamydia infection that has not been treated, the risk of the neonate developing Chlamydia conjunctivitis is 20-50% and the risk of Chlamydia pneumonia is 5-10%.

Antimicrobial

Prophylactic antibiotics are not effective at preventing Chlamydia conjunctivitis or pneumonia in neonates.

Comments and Duration of Therapy

For all cases also treat mother and sexual partner. See Chlamydia infection of urethra, endocervix or rectum in Genital Infections.

Families should be advised to monitor baby for signs of conjunctivitis or pneumonia and present early for treatment.

Neonatal Conjunctivitis or Gonococcal Ophthalmia Neonatorum

Conjunctivitis may be associated with a blocked tear duct, or bacterial colonization with oropharyngeal flora. Congenitally acquired infections including Gonorrhoea and Chlamydia can also cause severe, sight threatening conjunctivitis. Gonococcal conjunctivitis usually presents in the first two weeks of life with sudden, severe, grossly purulent conjunctivitis. It can rapidly lead to perforation of the globe and blindness. Topical antibiotics alone are insufficient.

Urgent review by Ophthalmology is required.

Antimicrobial

Irrigate the eye with saline several times a day until purulence subsides.

Ceftriaxone 50mg/kg IV/IM single dose

PLUS

Azithromycin 20mg/kg PO OD

If there is evidence of disseminated Gonococcal disease:

Cefotaxime 50mg/kg IV TID in first week of life, QID after first week of life

Ceftriaxone 50mg/kg IV OD

Comments and Duration of Therapy

Send bacterial swab for culture. Send viral (dry) swab for PCR. If disseminated disease is suspected (see below) send blood cultures, CSF and synovial fluid where clinically indicated.

Exclude disseminated gonococcal infection by careful physical examination. Disseminated disease may present as sepsis, arthritis, meningitis, or skin abscesses.

Neonatal gonococcal infection is preventable with prophylactic antibiotics for babies born to mothers with known gonococcal infection (see above).

The infant’s mother and her partner should be tested and treated for Gonorrhoea, see Gonorrhoea in Genital Infections.

Duration:

Azithromycin: Treat for 3 days
Disseminated Gonococcal disease: Treat for 10 days

Neonatal oral candidiasis (thrush) prophylaxis

Antimicrobial

Indicated if any of the following:

< 32 weeks CGA
Receiving antibiotics for > 7 days
On CPAP

Nystatin 100 000 IU/ml PO 1ml TID

Comments and Duration of Therapy

Duration:

Continue until tolerating full enteral feeds, and antibiotics ceased for 48 hours.

Neonatal oral candidiasis (thrush) treatment

Antimicrobial

Nystatin 100 000 IU/ml PO 1ml QID

Treat mother’s breast with:

Miconazole 2% cream topically BID

Gentian violet topically BID

Comments and Duration of Therapy

Duration:

Neonate: Treat for 7-10 days
Mother: Continue until 2 weeks after symptom resolution.

See Oral thrush (Candidiasis) in Gastrointestinal infections, Candida Oesophagitis in Gastrointestinal infections, Cutaneous Candidiasis in Skin and Soft Tissue Infection and Vulvovaginal Candidiasis in Women’s Health

Neonatal Syphilis prophylaxis / treatment

Babies born to mothers with Syphilis should be assessed for clinical evidence of congenital Syphilis. The risk of transmission from mothers with early Syphilis is 40-90%, in late Syphilis it is <10%. Symptoms or signs may include growth restriction, respiratory distress, rash (palms / soles), mucosal lesions, anaemia, jaundice, hepatosplenomegaly, nasal discharge, bony tenderness or periostitis on x-ray.

See also Syphilis in Pregnancy in Genital Infections chapter.

Antimicrobial

Asymptomatic babies born to mothers with syphilis (even if treated during pregnancy):

Benzathine Penicillin 50 000 IU (37.5mg)/kg IM single dose

Babies with probable congenital syphilis (positive examination findings or other investigations, and/or nontreponemal test ≥ four times maternal titre):

Benzylpenicillin 100 000 IU (60mg)/kg IV/ IM BID

Consider treating as probable congenital syphilis, babies with normal physical examination and nontreponemal test < four times maternal titre, whose mothers were not treated, were inadequately treated, or have evidence of reinfection or relapse.

Comments and Duration of Therapy

Send serum for nontreponemal testing (VDRL, RPR). If baby’s nontreponemal titre is four times the maternal titre congenital syphilis is highly likely. Consider LP in all babies with possible congenital syphilis.

For all cases also treat the mother and sexual partner and notify the case to Ministry of Health. See Syphilis in Genital Infections, and Syphilis in Pregnancy in Genital Infections.

Duration:

Babies with probable congenital syphilis (including CNS disease): Treat for 14 days.

Repeat nontreponemal testing in all infants born to mothers with syphilis every 2-3 months until this become nonreactive or titre has decreased fourfold. If this fails to decline or increases after 6-12 months, perform LP and repeat 14-day treatment course.

Neonatal HIV Prophylaxis

If measures are not put in place to prevent mother-to-child transmission of HIV, the risk of transmission from an infected mother to the baby is approximately 40%. It is possible to reduce this risk by using antiretroviral therapy (ART) during the antenatal period to control viral replication in the mother. All pregnant women who have HIV should be commenced on ART immediately, and all exposed infants should also be treated with ART as soon as possible. Ideally within 6 hours of birth.

Refer to local HIV team and Infectious Diseases where available.

See Timor-Leste Comprehensive ART Guidelines.

Antimicrobial

Low risk babies (see comments):

Zidovudine PO BID
≥ 35 weeks gestation: 4mg/kg PO BID for 4 weeks
30-34 weeks gestation: 2mg/kg PO BID for 2 weeks, then TID for 2 weeks
<30 weeks gestation: 2mg/kg PO BID for 4 weeks

If unable to tolerate PO, give IV zidovudine:

Term neonate: 1.5mg/kg IV QID

Premature: 1.5mg/kg IV BID

High risk babies (see comments):

Zidovudine (dose as above) for 4 weeks

PLUS

Lamivudine 2mg/kg PO BID for 4 weeks

PLUS

Nevirapine 2mg/kg PO OD for 1 week, then 4mg/kg for 1 week then stop
(if mother was taking nevirapine for at least 3 days prior to birth use 4mg/kg for 2 weeks)

PLUS

Cotrimoxazole 5+25mg/kg PO OD from 6 weeks of age, until confirmed HIV negative.

Comments and Duration of Therapy

All babies at risk of mother-to-child transmission of HIV should be tested using HIV proviral DNA or HIV RNA PCR at 1 and 6 weeks, and 3 months. HIV antibody testing should be performed at 18 months. Refer to the National ART Guidelines if HIV infection is confirmed.

Babies are low risk if:

Mother is on ART and viral load <50 copies/ml within 4 weeks of delivery AND
Mother did not acquire HIV during pregnancy

Babies are high risk if:

Mother received ART but viral load >50 copies/ml within 4 weeks of delivery
Mother acquired HIV during pregnancy
Mother did not receive ART during pregnancy
Mother only received intrapartum ART

Exclusive breastfeeding until the baby is 6 months should be encouraged. Mixed breast and formula feeding increases the risk of transmission of HIV considerably.

See HIV infection in Special Infections

Neonatal TB Prophylaxis

Risk of transmission is reduced once a pregnant woman has been on treatment for >2 weeks. Congenital and perinatal TB transmission occur rarely, but the associated mortality when transmission does occur is high (~50%).

Antimicrobial

Isoniazid 10mg (range 7-15mg, max 300mg) PO OD for 6 months

Alternative:

Rifampicin 15mg (range 10-20mg, max 600mg) PO OD

PLUS

Isoniazid 10mg/kg (range 7-15mg, max 300mg)

After treatment completion give:

BCG vaccination

Comments and Duration of Therapy

Neonates born to mothers with confirmed TB whose treatment was started <2 weeks prior should be examined carefully to exclude TB disease. Asymptomatic babies should not receive the BCG vaccine until they have completed preventative therapy.

If tuberculosis is confirmed see Timor-Leste Comprehensive TB Guidelines for National Tuberculosis Control Program

During the course of treatment, adjust drug doses for weight gain in the infant.

Duration:

Isoniazid monotherapy: Treat for 6 months

Rifampicin + isoniazid: Treat for 3 months

See Paediatric TB in Paediatric Infections (Neonates, Infants and Children),and Tuberculosis (TB) in ENT/Respiratory Tract infections

Neonatal Herpes Simplex Virus Prophylaxis / Treatment

Asymptomatic babies born to mothers with a first episode of genital herpes around the time of delivery have a high risk (~30%) of neonatal herpes disease. Those that are infected have a high risk (~30%) of severe, disseminated or CNS disease. Prophylaxis is indicated for these babies.

Antimicrobial

For asymptomatic babies and initial treatment for symptomatic babies:

Acyclovir 20mg/kg IV TID

Alternative (not preferred):

Acyclovir 20mg/kg PO 5 times a day

Suppression for symptomatic babies after completing initial treatment:

Acyclovir 20mg/kg PO TID

Comments and Duration of Therapy

Perform lumbar puncture and request HSV PCR (Biofire multiplex) where available. Repeat lumbar puncture at 2-3 weeks in CNS disease to check for cure.

Duration:

Asymptomatic: Treat for 10 days
Initial treatment skin, eye, and mouth disease: Treat for 14 days.
Initial treatment disseminated or CNS disease: Treat for at least 21 days. Continue for longer if CSF HSV PCR remains positive.
Suppression: Continue for 6 months.

See also Encephalitis in Central Nervous System Infections, Dendritic corneal ulceration caused by Herpes Simplex virus in Eye Infections, Genital Herpes simplex virus in Genital Infections, and Herpes Simplex in Skin and Soft Tissue Infections

Neonatal Varicella Zoster Virus Prophylaxis / Treatment

The highest risk of neonatal chickenpox occurs when babies are born to mothers who have their first episode of chickenpox from 7 days before to 28 days after delivery. Horizontal transmission can also occur from other household members to a baby born to a mother with no prior history of chickenpox.

Antimicrobial

Asymptomatic babies born to mothers with recent chickenpox (7 days before - 28 days after delivery) use:

Varicella Zoster Immunoglobulin (if available)

Symptomatic neonates:

Acyclovir 20mg/kg IV TID

Alternative (not preferred):

Acyclovir 20mg/kg PO 5 times a day

Comments and Duration of Therapy

Neonatal chickenpox is life-threatening, with estimated case fatality rates of up to 30%. Features may include fever, vesicular rash, pneumonia, meningoencephalitis, or hepatitis.

Isolate from other babies and use contact precautions.

Duration:

Symptomatic neonates: Treat for 10 days

See Herpes Zoster / Shingles in Skin and Soft Tissue Infection, and Varicella infection (chickenpox) in Special Infections

Hepatitis B in Neonates

Hepatitis B transmission from mother to child is common in untreated mothers with e-antigen positive chronic hepatitis B, in the absence of vaccination (up to 90%). Birth dose Hepatitis B vaccination prevents approximately 75% of transmission, while the addition of Hepatitis B immunoglobulin may improve protection against transmission to approximately 90%. Mothers with hepatitis B should be encouraged to breastfeed.

Antimicrobial

Hepatitis B vaccine IM as soon as possible after birth preferably within 12 hours of delivery

AND

Hepatitis B Immunoglobulin (HBIG) 0.5ml IM (if available)

Followed by:

Refer to the Childhood Immunisation Schedule to perform a full Hepatitis B vaccination regimen

Babies with low birth weight (<2kg) do not respond as well to the vaccine. Consider a booster Hepatitis B vaccine at 12 months on top of the usual regimen.

Comments and Duration of Therapy

If access to the Hepatitis B vaccine becomes limited in Timor-Leste, babies born to mothers with Hepatitis B should be prioritized for administration of the hepatitis B vaccine.

See Chronic Hepatitis B in Gastrointestinal Infections

Childhood Malnutrition

In severe acute malnutrition, the usual signs of bacterial infection such as fever are often absent. Multiple infections are common. If specific infections are identified treat for these, otherwise, in all children with severe acute malnutrition, give the following antibiotics empirically.

Antimicrobial

Severe acute malnutrition in children with no signs of infection and who do not appear unwell:

Amoxicillin 40-45mg/kg PO BID

Alternative:

Cotrimoxazole 4/20 mg/kg PO BID

Severe acute complicated malnutrition with oedema or looking unwell:

Ampicillin 50mg/kg IV/IM QID

PLUS

Gentamicin 7.5mg/kg IV OD

Severe acute malnutrition with signs of severe infection or meningitis:

Ceftriaxone 50mg/kg IV BID

If refractory diarrhoea ADD:

Metronidazole 12.5mg/kg IV BID

Comments and Duration of Therapy

Send blood cultures.
Consider treating as Sepsis if child is lethargic, hypothermic or hypoglycaemic.

Duration:

SAM in children with no signs of infection and not unwell: Treat for 7 days SAM with oedema or looking unwell: Step down to orals once improving. Treat for a total of 7 days.
SAM with signs of severe infection or meningitis: Treat according to suspected source of infection. If this is not obvious treat for 7 days.

Pertussis in Children

Consider pertussis if the child has a whooping-type cough, persistent cough, post-cough vomiting, or apnoeic or cyanotic episodes. Fever is uncommon.

Antimicrobial

Infants < 6 months:

Azithromycin 10 mg/kg PO OD

Infants ≥ 6 months and children:

Azithromycin 10mg/kg single dose on day 1; then 5mg/kg PO OD

Alternative:

Co-trimoxazole child 4/20 mg/kg PO BID for infants and children > 1 month

Clarithromycin 7.5mg/kg PO BID

Comments and Duration of Therapy

There is no conclusive evidence that antibiotics alter the course of disease, but treatment of Pertussis minimises the transmission to susceptible contacts. Patients should avoid contact with others, especially young children and infants, until at least 5 days of antibiotic therapy have been taken.

Duration:

Azithromycin: Treat for 5 days.
Co-trimoxazole, Clarithromycin: Treat for 7 days

See Community acquired pneumonia (CAP) in children in ENT / Respiratory Tract infections

Paediatric TB

Suspect TB if any two of the following:

Recent TB contact
Cough > 2 weeks
Fever >2 weeks
Failure to thrive
Fatigue / reduced playfulness >2 weeks
Lymphadenopathy (>1cm) >2 weeks
Profuse night sweats

Antimicrobial

See Timor-Leste Comprehensive TB Guidelines for National Tuberculosis Control Program

See also Tuberculosis (TB) section in ENT / Respiratory chapter.

Comments and Duration of Therapy

Examine for signs of extra-pulmonary TB:

Pleural effusion
Enlarged non-tender lymph nodes, mainly cervical.
Signs of meningitis
Abdominal swelling with or without palpable masses
Progressive swelling or deformity in the bone or a joint, including the spine

Send sputum, gastric aspirate, pus, lymph node, joint aspirate, CSF for GeneXpert PCR, AFB and culture. Consider performing blood culture (request prolonged incubation in Bactec) if disseminated TB is suspected or there is significant immunocompromise.

Test all patients for HIV.
See Neontal TB prophylaxis in Paediatric Infections (Neonates, Infants and Children),and Tuberculosis (TB) in ENT / Respiratory Tract infections

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