# Fast Facts: Pediatric Antibiotics - [**Acute Bacterial Conjunctivitis**](#bkmrk-acute-bacterial-conj-1) - [**Acute Bacterial Rhinosinusitis (Sinus Infection)**](#bkmrk-acute-bacterial-rhin) - [**Acute Lymphadenitis (Swollen Lymph Nodes)**](#bkmrk-acute-lymphadenitis) - [**Acute Otitis Media (AOM)**](#bkmrk-acute-otitis-media-%28) - [**Animal Bites**](#bkmrk-animal-%2F-human-bites) - [**Atypical Pneumonia (Walking Pneumonia)**](#bkmrk-atypical-pneumonia) - [**Cellulitis**](#bkmrk-cellulitis-%2F-abscess) - [**Conjunctivitis (Pink Eye)**](#bkmrk-acute-bacterial-conj-1) - [**Cystitis (Bladder Infection, Uncomplicated UTI)**](#bkmrk-cystitis-%28uncomplica) - [**Dental Abscess**](#bkmrk-dental-abscess) - [**Group A Streptococcal Pharyngitis (Strep Throat)**](#bkmrk-group-a-streptococca) - [**Human Bites**](#bkmrk-animal-%2F-human-bites) - [**Impetigo**](#bkmrk-impetigo) - [**Otitis Externa (Swimmer’s Ear)**](#bkmrk-acute-otitis-media-%28) - [**Otorrhea (Ear Discharge)**](#bkmrk-otorrhea-%2F-otitis-ex) - [**Pertussis (Whooping Cough)**](#bkmrk-pertussis) - [**Pneumonia**](#bkmrk-uncomplicated-pneumo) - [**Pyelonephritis (Kidney Infection, Febrile UTI)**](#bkmrk-pyelonephritis-%28febr) - [**Sinus Infection (Acute Bacterial Rhinosinusitis)**](#bkmrk-acute-bacterial-rhin) - [**Strep Throat (Group A Streptococcal Pharyngitis)**](#bkmrk-group-a-streptococca) - [**Swimmer’s Ear (Otitis Externa)**](#bkmrk-otorrhea-%2F-otitis-ex) - [**Walking Pneumonia (Atypical Pneumonia)**](#bkmrk-atypical-pneumonia) - [**Whooping Cough (Pertussis)**](#bkmrk-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.