Fast Facts: Pediatric Antibiotics

ACUTE OTITIS MEDIA (AOM)

Watchful waiting (WW) / Safety-Net Antibiotic Prescription (SNAP):
- Joint decision between provider and caregiver
- Must have close follow-up (within 48–72 hours) if SNAP not given
- Must be able to fill antibiotic prescription if signs/symptoms worsen or fail to improve in 48–72 hours from onset
- Note: If using WW/SNAP, place a comment in prescription instructions: “Fill only upon patient/family request”
Antibiotic Recommendations
- Duration:
  - <2 years or severe disease: 10 days
  - 2–5 years: 7 days
  - ≥6 years: 5 days
  - Recent data suggests 5 days may be sufficient for children >2 years with AOM of any severity
    - (Frost et al. J Pediatr. 2020 May; 220:109-115.e1).
- First-line therapy:
  - Amoxicillin 40–50 mg/kg/dose BID (max 2000 mg/dose)
- If received amoxicillin within the past 30 days, in daycare, or with concomitant conjunctivitis:
  - Amoxicillin/clavulanate 40–50 mg/kg/dose (amoxicillin component) PO BID (max 2000 mg amoxicillin/dose)
- Penicillin Allergy:
  - Mild/Moderate—Rashes, including hives:
    - Cefuroxime: 250 mg PO BID (tablets only, not crushable)
    - Cefdinir: 7 mg/kg/dose PO BID (max 300 mg/dose)
    - Cefpodoxime: 5 mg/kg/dose PO BID (max 200 mg/dose)
    - Cefprozil: 15 mg/kg/dose PO BID (max 500 mg/dose)
    - Ceftriaxone: 50 mg/kg/dose IM/IV qDay x 1–3 days (max 1000 mg/dose)
  - Severe—Anaphylaxis:
    - Clindamycin 10 mg/kg/dose PO TID (max 600 mg/dose)
- Failure to improve after 48–72 hours of initial antibiotic therapy:
  - Treatment failure with amoxicillin:
    - Amoxicillin/clavulanate 40–50 mg/kg/dose (amoxicillin component) PO BID (max 2000 mg amoxicillin/dose)
  - Treatment failure with amoxicillin/clavulanate:
    - Ceftriaxone 50 mg/kg/dose (max 1000 mg/dose) IM or IV daily x 3 days
    - Clindamycin 10 mg/kg/dose PO TID (max 600 mg/dose) PLUS:
      - Cefuroxime 250 mg PO BID
      - Cefpodoxime 5 mg/kg/dose PO BID (max 200 mg/dose)

OTORRHEA / OTITIS EXTERNA

Perforated Tympanic Membrane (+ Oral Antibiotics) OR AOM with Tubes:
- Ciprodex (ciprofloxacin/dexamethasone): 4 drops BID x 7 days for patients >6 months.
- Alternative (if Ciprodex is unavailable or cost-prohibitive):
  - Ciprofloxacin ophthalmic solution: 2 drops +/- dexamethasone ophthalmic solution: 2 drops BID x 7 days for patients >6 months.
- Ofloxacin otic solution: 5 drops BID x 10 days for patients >6 months.
Intact Tympanic Membrane (Non-complicated Otitis Externa):
- Ciprodex (ciprofloxacin/dexamethasone): 4 drops BID x 7 days.
- Ofloxacin otic solution: 5 drops BID x 10 days.
- Cortisporin otic solution: 3 drops TID x 7 days.
Additional Considerations:
- Ear wick placement may help deliver medication to the site of infection, especially in cases of significant canal swelling.
- Pain management (e.g., acetaminophen or ibuprofen) is critical for patient comfort.
Notes:
- Ensure proper administration technique to maximize effectiveness (e.g., warming drops before application and keeping the ear tilted for several minutes post-application).
- If symptoms persist or worsen after 48–72 hours, reassess for alternative diagnoses or complications.

GROUP A STREPTOCOCCAL PHARYNGITIS

First-line therapy:
- Amoxicillin: 50 mg/kg/dose PO BID (max 1000 mg/day) x 10 days
- Bicillin L-A (Penicillin G benzathine): IM
  - <27 kg: 600,000 U x 1 dose
  - ≥27 kg: 1.2 million U x 1 dose
- Penicillin VK: PO
  - <27 kg: 250 mg BID-TID x 10 days
  - ≥27 kg: 500 mg BID-TID x 10 days
Penicillin Allergy:
- Mild—Rashes, including hives:
  - Cephalexin: 20–25 mg/kg/dose PO BID (max 500 mg/dose) x 10 days
- Severe—Anaphylaxis:
  - Clindamycin: 7 mg/kg/dose PO TID (max 300 mg/dose) x 10 days
  - Azithromycin: 12 mg/kg/dose PO qDay (max 500 mg/dose) x 5 days
Notes:
- Azithromycin is not recommended unless the patient has a severe allergy to both penicillins and cephalosporins. Resistance is well-known, and treatment failure may occur.

UNCOMPLICATED PNEUMONIA

Duration:
- 5 days
- Note: Shorter duration of 3–5 days may be sufficient for patients >6 months old (Kuitunen et al. Clin Infect Dis. 2023 Feb 8;76(3):e1123-e1128).
First-line therapy:
- Amoxicillin: 40–50 mg/kg/dose PO BID (max 2000 mg/dose)
- Note: Amoxicillin/clavulanate provides no additional coverage for Streptococcus pneumoniae and is not recommended as a first-line agent.
Penicillin Allergy:
- Mild/Moderate—Rashes, including hives:
  - Cefuroxime: 250–500 mg PO BID (for children able to swallow pills; only available in tablets)
  - Cefpodoxime: 5 mg/kg/dose PO BID (max 200 mg/dose)
  - Cefprozil: 15 mg/kg/dose PO BID (max 500 mg/dose)
- Note: Cefdinir is NOT recommended for empiric treatment of community-acquired pneumonia due to reduced effectiveness against Streptococcus pneumoniae. Clindamycin is preferred if above options are unavailable.
- Severe—Anaphylaxis ± Cephalosporin Allergy:
  - Clindamycin: 10 mg/kg/dose PO TID (max 600 mg/dose)
- Severe—Anaphylaxis + Cephalosporin Allergy + Intolerance of Clindamycin:
  - Levofloxacin:
    - Ages 6 months–5 years: 8–10 mg/kg/dose PO BID
    - ≥5 years: 16–20 mg/kg/dose PO QD (max 750 mg/day)

ATYPICAL PNEUMONIA

Duration:
- 5–7 days
First-line therapy:
- Azithromycin:
  - Day 1: 10 mg/kg/dose PO (max 500 mg/dose)
  - Days 2–5: 5 mg/kg/dose PO qDay (max 250 mg/dose)
- Note: Resistance to azithromycin is significant among typical bacterial pathogens, especially Streptococcus pneumoniae.
Alternatives (without azithromycin):
- Levofloxacin:
  - Ages 6 months–5 years: 8–10 mg/kg/dose PO BID
  - ≥5 years: 16–20 mg/kg/dose PO QD (max 750 mg/day)
- Doxycycline (for children ≥8 years):
  - 2 mg/kg/dose PO BID (max 100 mg/dose)
Notes:
- Consider atypical pneumonia in adolescents with bilateral or diffuse pulmonary involvement and/or prolonged symptoms such as persistent cough and fever.
- Levofloxacin and doxycycline provide excellent atypical pathogen coverage and do not require additional macrolides.

ACUTE BACTERIAL RHINOSINUSITIS (ABRS)

Criteria for Diagnosis:
- Presumptive diagnosis of ABRS can be made if a patient with acute upper respiratory tract infection (URI) presents with ONE of the following:
  - Persistent illness (e.g., nasal discharge, daytime cough, or both) lasting >10 days without improvement.
  - Worsening course after initial improvement (e.g., new onset nasal discharge, daytime cough, or fever).
  - Severe onset (e.g., fever ≥102.2°F and purulent nasal discharge) lasting at least 3 consecutive days.
Duration:
- 5–7 days
First-line therapy:
- Mild-moderate disease (≥2 years, no daycare, no antibiotics in past 30 days):
  - Amoxicillin: 45–50 mg/kg PO BID (max 2000 mg/dose).
- Severe disease or mild-moderate disease with any of the following: <2 years, daycare attendance, or recent antibiotic use:
  - Amoxicillin-clavulanate: 40–50 mg/kg/dose (amoxicillin component) PO BID (max 2000 mg/dose).
Penicillin Allergy:
- Mild/Moderate—Rashes, including hives:
  - Cefpodoxime: 5 mg/kg/dose PO BID (max 200 mg/dose).
  - Cefuroxime: 250 mg PO BID (for children able to swallow tablets; not available in liquid form).
  - Cefixime: 4 mg/kg/dose PO BID (max 200 mg/dose) PLUS Clindamycin: 10 mg/kg/dose PO TID (max 600 mg/dose).
- Severe—Anaphylaxis ± Cephalosporin Allergy:
  - Levofloxacin:
    - Ages 6 months–5 years: 10 mg/kg/dose PO BID.
    - ≥5 years: 20 mg/kg/dose PO QD (max 500 mg/day).
Notes:
- If symptoms worsen or fail to improve after 48–72 hours, reassess for complications or switch to second-line therapy.
- Consider consulting an infectious diseases physician for complex or recurrent cases.

CYSTITIS (UNCOMPLICATED UTI)

Duration:
- 3–5 days
First-line therapy:
- Cephalexin: 50 mg/kg/day PO divided TID (max 1500 mg/day).
- Cefixime: 8 mg/kg/dose PO qDay (max 400 mg/day).
Severe Penicillin/Cephalosporin Allergy (e.g., Anaphylaxis):
- Trimethoprim-Sulfamethoxazole (TMP/SMX):
  - 3–6 mg TMP/kg/dose PO BID (max 160 mg TMP/dose).
- Nitrofurantoin (for cystitis only):
  - Macrocrystal (Macrodantin or Furadantin): 1.25–1.75 mg/kg/dose PO Q6H x 5–7 days (max 100 mg/dose).
  - Macrocrystal/monohydrate (Macrobid): 100 mg PO BID x 5–7 days (adolescents only).
Notes:
- Nitrofurantoin should be used only for lower urinary tract infections and avoided in suspected pyelonephritis or febrile UTIs.
- Avoid TMP/SMX in infants <2 months due to risk of kernicterus.
- Consider urine culture and sensitivity for recurrent UTIs or treatment failures.

PYELONEPHRITIS (FEBRILE UTI)

Indications for Admission:
- Age <2 months.
- Ill appearance or poor oral intake.
- Inability to tolerate oral antibiotics.
- Vomiting, immune compromise, or urinary tract obstruction.
- Positive culture for bacteria resistant to oral antibiotics.
Duration:
- 7–10 days.
- Note: Shorter duration of 5 days may be sufficient for patients >2 months (Zaoutis et al., JAMA Pediatr. 2023 Aug 1;177(8):782-789).
First-line therapy:
- Cephalexin: 25–33 mg/kg/dose PO TID (max 3000 mg/day).
- Cefixime: 8 mg/kg/day PO qDay (max 400 mg/day).
Severe Penicillin/Cephalosporin Allergy (e.g., Anaphylaxis):
- Trimethoprim-Sulfamethoxazole (TMP/SMX):
  - 3–6 mg TMP/kg/dose PO BID (max 160 mg TMP/dose).
- Ciprofloxacin:
  - 10–20 mg/kg/dose PO BID (max 750 mg/dose).
Notes:
- Cefdinir is not recommended for pediatric UTIs due to poor urine concentration in children.
- Evaluate for potential complications, such as renal scarring or obstruction, especially in recurrent infections.
- Obtain urine culture and sensitivity to guide therapy.

IMPETIGO

Treatment based on severity:
- Mild (<5 lesions - topical therapy):
  - Mupirocin: Apply TID x 5 days.
- Extensive (>5 lesions or lesions near the mouth - systemic therapy):
  - Cephalexin: 17 mg/kg/dose PO TID (max 500 mg/dose) x 7 days.
- If MRSA is suspected or with severe penicillin/cephalosporin allergy:
  - Clindamycin: 7 mg/kg/dose PO TID (max 450 mg/dose) x 7 days.
  - Trimethoprim-Sulfamethoxazole (TMP/SMX):
    - 4–6 mg TMP/kg/dose PO BID (max 160 mg TMP/dose) x 7 days.
Notes:
- Systemic antibiotics are preferred if lesions are numerous, involve the mouth or mucosal areas, or in cases with signs of systemic infection.
- Educate caregivers about proper hygiene to prevent the spread, as impetigo is highly contagious.

CELLULITIS / ABSCESS

First-line therapy:
- Cephalexin: 17 mg/kg/dose PO TID (max 500 mg/dose) x 5 days.
- Amoxicillin-clavulanate: 22.5 mg/kg/dose (amoxicillin component) PO BID (max 875 mg/dose).
If MRSA is suspected, abscess is present, or in cases of penicillin/cephalosporin allergy:
- Clindamycin: 10 mg/kg/dose PO TID (max 450 mg/dose) x 5 days.
- Trimethoprim-Sulfamethoxazole (TMP/SMX):
  - 4–6 mg TMP/kg/dose PO BID (max 160 mg TMP/dose) x 5 days.
Notes:
- For abscesses, incision and drainage (I&D) is the primary treatment; antibiotics may be considered based on the severity or associated cellulitis.
- Reassess therapy if no improvement is noted after 48–72 hours.
- Obtain cultures in cases of recurrent abscesses, systemic symptoms, or immunocompromised patients to guide therapy.

ANIMAL / HUMAN BITES

First-line therapy:
- Amoxicillin-clavulanate (Augmentin): 22.5 mg/kg/dose (amoxicillin component) PO BID (max 875 mg amoxicillin/dose).
Duration:
- Prophylaxis: 3 days.
- Treatment: 5–7 days.
Penicillin Allergy:
- Clindamycin: 10 mg/kg/dose PO TID (max 450 mg/dose) PLUS one of the following:
  - Trimethoprim-Sulfamethoxazole (TMP/SMX): 5 mg TMP/kg/dose PO BID (max 160 mg TMP/dose).
  - Doxycycline: 2.2 mg/kg/dose PO BID (max 100 mg/dose).
Additional Considerations:
- Tetanus booster: Ensure vaccination status is updated.
- Rabies prophylaxis: Assess need based on the animal and circumstances of the bite.
Notes:
- Antibiotic prophylaxis is recommended for high-risk wounds, such as deep punctures, crush injuries, or bites on the hands, face, or genitals.
- Monitor for signs of infection, including increasing redness, swelling, pain, or systemic symptoms.

DENTAL ABSCESS

First-line therapy:
- Amoxicillin: 17 mg/kg/dose PO TID (max 500 mg/dose) x 10 days.
- Amoxicillin-clavulanate (Augmentin): 25 mg/kg/dose (amoxicillin component) PO BID (max 875 mg amoxicillin/dose) x 10 days.
If buccal involvement or penicillin allergy:
- Clindamycin: 10 mg/kg/dose PO TID (max 450 mg/dose) x 10 days.
Additional Considerations:
- Incision and drainage (I&D) is often necessary for definitive management.
- Dental consultation is recommended to address the underlying cause and prevent recurrence.
Notes:
- For systemic symptoms (e.g., fever, swelling extending into facial spaces), hospitalization and IV antibiotics may be required.
- Encourage dental hygiene and follow-up care to prevent complications or recurrence.

ACUTE LYMPHADENITIS

First-line therapy:
- Cephalexin: 17–25 mg/kg/dose PO TID (max 1000 mg/dose) x 7–10 days.
- Amoxicillin-clavulanate (Augmentin): 22.5 mg/kg/dose (amoxicillin component) PO BID (max 875 mg amoxicillin/dose) x 7–10 days.
If MRSA is suspected or with severe penicillin/cephalosporin allergy:
- Clindamycin: 10 mg/kg/dose PO TID (max 450 mg/dose) x 7–10 days.
If Bartonella henselae (cat-scratch disease) is suspected:
- Azithromycin: 10 mg/kg/dose PO qDay (max 500 mg/dose) x 5 days.
Additional Considerations:
- Obtain cultures or imaging (e.g., ultrasound) if abscess formation is suspected.
- Monitor closely for systemic symptoms such as fever, weight loss, or night sweats, which may warrant further investigation for atypical infections or malignancy.
Notes:
- Typical bacterial causes include Staphylococcus aureus and Streptococcus pyogenes.
- For children with recurrent or persistent lymphadenitis, consider consultation with an infectious diseases specialist.

ACUTE BACTERIAL CONJUNCTIVITIS

Infants (especially <2 months):
- Erythromycin ointment (5 mg/g): Apply 1 cm to the affected eye QID for 5 days.
- Polymyxin B ointment: Apply 1.25 cm to the affected eye QID for 5 days.
Children and adolescents:
- Polymyxin B solution: 1 drop in the affected eye QID for 7 days.
Alternative topical therapies:
- Tobramycin (0.3%) ophthalmic solution: Instill 1–2 drops into the affected eye every 4 hours.
- Azithromycin (1%) ophthalmic solution:
  - Instill 1 drop into the affected eye BID (8–12 hours apart) on days 1–2.
  - Then, instill 1 drop daily into the affected eye on days 3–7.
  - Note: More expensive and harder to find than other alternatives.
If corneal involvement or patient wears contact lenses:
- Consider alternatives with broader gram-negative coverage:
  - Ciprofloxacin (0.3%) ophthalmic drops: Instill 1–2 drops in the affected eye 4 times daily.
  - Ofloxacin (0.3%) ophthalmic drops: Instill 1–2 drops in the affected eye 4 times daily.
Notes:
- Avoid ophthalmic solutions containing neomycin due to a high incidence of allergic reactions.
- For severe cases or if no improvement after 48 hours, consider bacterial resistance or alternative diagnoses such as viral conjunctivitis.

PERTUSSIS

Reportable - Must Notify Louisiana Department of Health; Must stay home until completed antibiotics

Indications for Treatment:
- Confirmed or suspected pertussis cases.
- Prophylaxis for close contacts of pertussis cases, especially high-risk individuals (e.g., infants, pregnant women, or those with immunocompromised household members).
Duration:
- 5–7 days depending on the selected antibiotic.
First-line therapy (macrolides):
- Azithromycin:
  - Infants <6 months: 10 mg/kg/dose PO qDay x 5 days
  - ≥6 months:
    - Day 1: 10 mg/kg/dose PO (max 500 mg/dose)
    - Days 2–5: 5 mg/kg/dose PO qDay (max 250 mg/dose)
- Clarithromycin:
  - 7.5 mg/kg/dose PO BID (max 500 mg/dose) x 7 days
Alternative therapy (if macrolides are contraindicated):
- Trimethoprim-Sulfamethoxazole (TMP/SMX):
  - 4–6 mg TMP/kg/dose PO BID (max 160 mg TMP/dose) x 14 days
Notes:
- Azithromycin is preferred for infants <1 month due to safety concerns with erythromycin (risk of hypertrophic pyloric stenosis).
- TMP/SMX should be avoided in infants <2 months due to the risk of kernicterus.
- Early treatment is critical to limit transmission, but treatment after the paroxysmal stage may not alter the course of symptoms.