Fast Facts: Pediatric Antibiotics

• Acute Bacterial Conjunctivitis
• Acute Bacterial Rhinosinusitis (Sinus Infection)
• Acute Lymphadenitis (Swollen Lymph Nodes)
• Acute Otitis Media (AOM)
• Animal Bites
• Atypical Pneumonia (Walking Pneumonia)
• Cellulitis
• Conjunctivitis (Pink Eye)
• Cystitis (Bladder Infection, Uncomplicated UTI)
• Dental Abscess
• Group A Streptococcal Pharyngitis (Strep Throat)
• Human Bites
• Impetigo
• Otitis Externa (Swimmer’s Ear)
• Otorrhea (Ear Discharge)
• Pertussis (Whooping Cough)
• Pneumonia
• Pyelonephritis (Kidney Infection, Febrile UTI)
• Sinus Infection (Acute Bacterial Rhinosinusitis)
• Strep Throat (Group A Streptococcal Pharyngitis)
• Swimmer’s Ear (Otitis Externa)
• Walking Pneumonia (Atypical Pneumonia)
• Whooping Cough (Pertussis)

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.