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Clinical Practice Guidelines

Antimicrobial guidelines


  • Statewide logo

    This guideline has been adapted for statewide use with the support of the Victorian Paediatric Clinical Network

  • CENTRAL NERVOUS SYSTEM / EYE

    Infection Likely organisms Initial antimicrobials1 (maximum dose) Duration of treatment2 and other comments
    Brain abscess

    Often polymicrobial
    S. milleri and other streptococci
    Anaerobes
    Gram-negatives
    S. aureus

    Flucloxacillin3 50 mg/kg (2 g) IV 6H and
    3rd gen cephalosporin4 and
    Metronidazole 15 mg/kg (1 g) IV stat, then 7.5 mg/kg (500 mg) IV 8H

    3 weeks minimum
    Penicillin hypersensitivity or risk of MRSA3: substitute Flucloxacillin with Vancomycin 15 mg/kg (500 mg) IV 6H

    Post-neurosurgery

    As above plus
    S. epidermidis

    As above but substitute Flucloxacillin with Vancomycin 15 mg/kg (500 mg) IV 6H

    Uncomplicated 10 days minimum
    Complicated 3 weeks minimum

    Encephalitis

    Herpes simplex virus
    Enteroviruses
    Arboviruses
    M. pneumoniae

    Aciclovir 20 mg/kg IV 12H (<30 weeks gestation), 8H (>30 weeks gestation to <3 months corrected age)
    500 mg/m2 IV 8H (3 months – 12 years)
    10 mg/kg IV 8H (>12 years)

    3 weeks minimum
    Consider adding Azithromycin if M. pneumoniae suspected
    Meningitis

    Over 2 months of age 

    S. pneumoniae5
    N. meningitidis
    H. influenzae type b6

    3rd gen cephalosporin4



    S. pneumoniae     10 days
    N. meningitidis 5–7 days
    H. influenzae type b 7–10 days
    Consider addition of Dexamethasone 0.15 mg/kg (10 mg) IV 6H for 4 days

    Over 2 months of age and possibility of penicillin-resistant pneumococci5

    As above

    3rd gen cephalosporin4 and
    Vancomycin 15 mg/kg (500 mg) IV 6H

    Under 2 months of age

    As above plus
    Group B streptococci
    E. coli and other Gram-negative coliforms
    L. monocytogenes

    Benzylpenicillin 60 mg/kg (2 g) IV
    12H (week 1 of life)
    6H (week 2–4 of life)
    4H (>week 4 of life) and Cefotaxime3

    Gram-negative 3 weeks
    GBS/Listeria 2–3 weeks
    Substitute Benzylpenicillin with Vancomycin if possibility of penicillin-resistant pneumococci5

    With shunt infection, post-neurosurgery, head trauma or CSF leak

    As for over 2 months of age plus S. epidermidis
    S. aureus
    Gram-negative coliforms incl. P. aeruginosa

    Vancomycin 15 mg/kg (500 mg) IV 6H and
    Ceftazidime 50 mg/kg (2 g) IV 8H

    10 days minimum

    Contact prophylaxis

    N. meningitidis

    Ciprofloxacin 250 mg (5–12 years) 500 mg (≥12 years) oral single dose
    Unable to take tablets: Rifampicin 5 mg/kg ( <1 month) or 10 mg/kg (≥1 month) (max 600 mg) oral bd for 2 days

    2 days

    Contact prophylaxis

    H. influenzae type b

    Rifampicin 20 mg/kg (600 mg) oral daily

    4 days

    Postseptal (orbital) cellulitis

    S. aureus
    H. influenzae spp.
    S. pneumoniae
    M. catarrhalis
    Gram-negatives
    Anaerobes

    Flucloxacillin3 50 mg/kg (2 g) IV 6H and
    3rd gen cephalosporin (dose for severe infection)4

    IV duration based on severity and improvement (usually 3-4 days)
    Switch to Amoxicillin/clavulanate (400/57 mg per 5 mL) 22.5 mg/kg (875 mg) (Amoxicillin component) = 0.3 mL/kg (11 mL) oral bd
    10 days minimum total duration
    Consider adding Metronidazole if not responding
    Preseptal (periorbital) cellulitis

    Mild

    Group A streptococci
    S. aureus
    H. influenzae spp.

    Cefalexin 33 mg/kg (500 mg) oral tds

    7–10 days

    Bilateral findings and/or painless or non-tender swelling in a well looking child is more likely to be an allergic reaction

    Moderate

    Flucloxacillin3 50 mg/kg (2 g) IV 6H or
    Ceftriaxone 50 mg/kg (2 g) daily (for hospital-in-the-home)

    Severe, or not responding, or under 5 years of age and non-Hib immunised

    As above plus
    H. influenzae type b6

    Flucloxacillin3 50 mg/kg (2 g) IV 6H and
    3rd gen cephalosporin4

    IV duration based on severity and improvement (usually 3-4 days)
    10 days minimum total duration

     

    CARDIOVASCULAR

    Infection Likely organisms Initial antimicrobials1 (maximum dose) Duration of treatment2 and other comments
    Endocarditis

    Native valve or homograft 

    Viridans streptococci
    Other streptococci
    Enterococcus spp.
    S. aureus

    Benzylpenicillin 60 mg/kg (2 g) IV 6H and
    Flucloxacillin3 50 mg/kg (2 g) IV 6H and
    Gentamicin 7.5 mg/kg (320 mg) IV daily (<10 years) 6 mg/kg (560 mg) IV daily (≥10 years)




    4–6 weeks
    Gentamicin 1 mg/kg (80 mg) IV 8H for 1–2 weeks when used only for synergy
    (Gentamicin monitoring is generally not required with low dose in this setting)

    Artificial valve, post-surgery or suspected MRSA4

    As above plus
    S. epidermidis

    Vancomycin 15 mg/kg (500 mg) IV 6H and
    Flucloxacillin3 50 mg/kg (2 g) IV 6H and
    Gentamicin 7.5 mg/kg (320 mg) IV daily (<10 years) 6 mg/kg (560 mg) IV daily (≥10 years)

    Endocarditis prophylaxis

    For dental procedures only 

    Viridans streptococci
    S. aureus
    S. pneumoniae
    Other Gram-positive cocci Enterococcus spp.

    Amoxicillin 50 mg/kg (2 g)
    Local anaesthetic: give orally 1 hour before procedure
    General anaesthetic: give IV with induction

    Penicillin hypersensitivity: substitute Amoxicillin with Cefalexin 50 mg/kg (2 g) oral
    Immediate or severe penicillin hypersensitivity: substitute with Clindamycin 20 mg/kg (600 mg) oral or IV

     

    GASTROINTESTINAL

    Infection Likely organisms Initial antimicrobials1 (maximum dose) Duration of treatment2 and other comments
    Diarrhoea
    Salmonella spp. isolated in infant under 3 months of age or in immunocompromised

    Salmonella spp.

    3rd gen cephalosporin4

    5–7 days
    Antibiotic treatment is generally unnecessary for most other organisms
    Consider adding Azithromycin in returned travellers from regions with high prevalence of cephalosporin resistance

    Antibiotic-associated

    C. difficile

    Metronidazole 7.5 mg/kg (400 mg) oral tds

    7–10 days

    Giardiasis

    G. lamblia

    Metronidazole 30 mg/kg (2 g) oral daily
    or
    Tinidazole 50 mg/kg (2 g) oral stat

    3 days

    Single dose

    Peritonitis or ascending cholangitis

    Gram-negative coliforms Anaerobes Enterococcus spp.

    Ampicillin or Amoxicillin 50 mg/kg (2 g) IV 6H and
    Gentamicin 7.5 mg/kg (320 mg) IV daily (<10 years) 6 mg/kg (560 mg) IV daily (≥10 years) and
    Metronidazole 15 mg/kg (1 g) IV stat, then 7.5 mg/kg (500 mg) IV 8H

    Up to 14 days
    See footnote 7 re Gentamicin dosing/monitoring

    Threadworm (Pinworm)

    Enterobius vermicularis

    Mebendazole 50 mg oral (<10 kg) 100 mg oral (≥10 kg)
    or
    Pyrantel 10 mg/kg (1 g) oral

    Single dose; may need to repeat after 14 days
    Treat whole family

     

    GENITOURINARY

    Infection Likely organisms Initial antimicrobials1 (maximum dose) Duration of treatment2 and other comments
    Urinary tract infection

    Over 6 months of age and not sick 

    E. coli
    P. mirabilis
    K. oxytoca
    Other Gram-negatives

    Cefalexin 33 mg/kg (500 mg) oral bd
    or
    Trimethoprim 4 mg/kg (150 mg) oral bd
    or
    Trimethoprim/Sulfamethoxazole (8/40 mg/mL) 0.5 mL/kg (20 mL) oral bd

    5 days

    Under 6 months of age or sick or acute pyelonephritis

    As above plus Enterococcus spp.

    Benzylpenicillin 60 mg/kg (2 g) IV 6H and
    Gentamicin 7.5 mg/kg (320 mg) IV daily (<10 years) 6 mg/kg (560 mg) IV daily (≥10 years) 5 mg/kg (320 mg) IV daily (week 1 of life)

    5–7 days for UTI
    10–14 days for pyelonephritis
    See footnote 6 re Gentamicin dosing/monitoring

    UTI prophylaxis

    As above

    Trimethoprim 2 mg/kg (150 mg) oral daily
    or
    Trimethoprim/Sulfamethoxazole (8/40 mg/mL) 0.25 mL/kg (20 mL) oral daily

    Routine prophylaxis is not recommended

     

    RESPIRATORY

    Infection Likely organisms Initial antimicrobials1 (maximum dose) Duration of treatment2 and other comments
    Epiglottitis

    H. influenzae type b6

    Ceftriaxone 50 mg/kg (1 g) IV daily

    5 days
    Consider addition of Dexamethasone

    Gingivostomatitis

    In immunocompromised 

     In immunocompetent (only if within 72 hours of onset with severe pain and dehydration)

    Herpes simplex virus

    Aciclovir 500 mg/m2 IV 8H (3 months–12 years) 10 mg/kg IV 8H (>12 years)

    Consider Aciclovir 10 mg/kg (400 mg) oral five times daily

    7 days

     

    Until no new lesions
    Newer

    Influenza

    Influenza A, B

    Oseltamivir
    3 mg/kg oral bd (Birth – 12 months)
    30 mg oral bd (>12 months and <15 kg)
    45 mg oral bd (15-23 kg)
    60 mg oral bd (23-40 kg)
    75 mg oral bd (>40 kg)

    5 days

    Otitis externa

    Acute diffuse 

    S. aureus
    S. epidermidis
    P. aeruginosa
    Proteus spp.
    Klebsiella spp.

    Topical steroid/antibiotic drops

    7 days
    Clean ear canal
    (± insertion of wick soaked in drops if ear canal oedematous)

    Acute localised (furuncle) ± cellulitis

    S. aureus
    Group A streptococci

    Flucloxacillin3 50 mg/kg (2 g) IV 6H

    5 days

    Failure of first-line treatment, high fever or severe persistent pain

    As above plus
    P. aeruginosa

    Piperacillin/Tazobactam 100 mg/kg (4 g) (Piperacillin component) IV 8H

    14 days minimum
    Consider fungal infection

    Otitis media

    Viruses
    S. pneumoniae
    M. catarrhalis
    H. influenzae spp.
    Group A streptococci

    Consider no antibiotics for 48 hours if over 6 months of age
    If treatment indicated
    Amoxicillin 30 mg/kg (1 g) oral bd

    5 days
    Treatment indicated if infection in one hearing ear or associated with cochlear implant

    Pertussis

    B. pertussis

    Azithromycin 10 mg/kg (500 mg) oral daily (Birth – 6 months), 10 mg/kg oral on Day 1, then 5 mg/kg (250 mg) daily (≥6 months)
    or
    Clarithromycin 7.5 mg/kg (500 mg) oral bd

    5 days



    7 days

    Can be given up to 3 weeks after contact with index case or if symptoms <3 weeks

    Pneumonia

    Mild (outpatient) 

    Viruses
    S. pneumoniae
    H. influenzae spp.

    Amoxicillin 30 mg/kg (1 g) oral tds

    3-5 days

    Moderate (inpatient)

    As above

    Amoxicillin 30 mg/kg (1 g) oral tds

    5 days
    Consider Benzylpenicillin 60 mg/kg (1.2 g) IV 6 H if unable to tolerate oral intake or vomiting

    Severe (≥2 of: severe respiratory distress, severe hypoxaemia or cyanosis, marked tachycardia, altered mental state OR empyema

    As above plus
    S. aureus
    Group A streptococci
    Gram-negatives

    Flucloxacillin3 50 mg/kg (2 g) IV 6H and
    3rd gen cephalosporin4

    10 days minimum2
    Consider adding Azithromycin 10 mg/kg (500 mg) IV daily to cover M. pneumoniae and other atypical pathogens and Oseltamivir to cover influenza virus

    Tonsillitis

    Viruses
    Group A streptococci (GAS)

    Features of GAS infection in child ≥4 years AND high-risk group or suppurative complications:
    Phenoxymethylpenicillin (Penicillin V) 250 mg oral bd (<20 kg) 500 mg oral bd (≥20 kg)
    or
    Benzathine benzylpenicillin 450mg (600 000 units) IM (<20 kg), 900 mg (1.2 million units) IM (>20 kg) as a single dose

    10 days oral treatment
    High-risk groups:

    • Indigenous Australians
    • Maori and Pacific Islander
    • Personal history of rheumatic fever or rheumatic heart disease
    • Family history of rheumatic fever or rheumatic heart disease
    • Immunosuppressed
    Quinsy (peritonsillar abscess)

     

    Amoxicillin/Clavulanate
    25 mg/kg (1 g) (Amoxicillin component) IV 8H (≥3 months and ≥4 kg)

    10 days

    Retropharyngeal abscess

     

    Amoxicillin/Clavulanate
    25 mg/kg (1 g) (Amoxicillin component) IV 8H (≥3 months and ≥4 kg)

    10-14 days

    SKIN/SOFT TISSUE/BONE

    Infection Likely organisms Initial antimicrobials1 (maximum dose) Duration of treatment2 and other comments
    Bites (animal/human)

    Viridans streptococci
    S. aureus
    Group A streptococci
    Oral anaerobes
    E. corrodens
    Pasteurella spp. (cat and dog)
    C. canimorsus (dog)

    Amoxicillin/Clavulanate (400/57 mg/5 mL) 22.5 mg/kg (875 mg) (Amoxicillin component) 0.3 mL/kg (11 mL) oral bd

    5 days
    Treat established infection
    Prophylaxis generally not required, except:

    • Presentation delayed >8 hours
    • Puncture wound unable to be adequately debrided
    • Bite on hands, feet, face
    • Bite involves deep tissues (e.g. bones, joints, tendons)
    • Bite involves an open fracture
    • Immunocompromised patient
    • Cat bites

    Check tetanus immunisation status

    If severe, penetrating injuries, esp. involving joints or tendons

    As above

    Amoxicillin/Clavulanate
    25 mg/kg (1 g) (Amoxicillin component) IV 12H (Birth – 3 months or <4 kg), 8H (≥3 months and ≥4 kg)

    14 days
    Increase to 6H in severe infections (≥3 months and ≥4 kg)

    Cellulitis

    Mild/moderate (outpatient)

    Group A streptococci
    S. aureus

    Cefalexin 33 mg/kg (500 mg) oral tds (1 g max for moderate cellulitis)

    5–10 days

    If rapidly progressive consider adding Clindamycin 10 mg/kg (600 mg) IV 6H

    Moderate/severe (inpatient)

    Flucloxacillin3 50 mg/kg (2 g) IV 6H
    or
    Ceftriaxone 50 mg/kg (2 g) IV daily (for hospital-in-the-home)

    Facial cellulitis in child under 5 years of age and non-Hib immunised

    As above plus
    S. pneumoniae
    H. influenzae spp.6

    Flucloxacillin3 50 mg/kg (2 g) IV 6H and
    3rd gen cephalosporin4

    Necrotising fasciitis

    As above

    Vancomycin 15 mg/kg (500 mg) IV 6H and
    Meropenem 20 mg/kg (1 g) IV 8H and
    Clindamycin 15 mg/kg (600 mg) IV 8H

    Consider IVIg
    Dental abscess

    Often polymicrobial
    Viridans and anginosus group streptococci
    Oral anaerobes
    S. aureus

    Amoxicillin 25 mg/kg (500 mg) oral tds or Benzylpenicillin 50 mg/kg (1.2g) IV 6H

    7 days
    Dental/surgical management required

    Head lice

    Pediculus humanus var. capitis

    1% permethrin liquid or cream rinse

    Repeat after one week

    Impetigo

    Group A streptococci
    S. aureus

    Mupirocin 2% ointment top 8H if localised
    or
    Cefalexin 33 mg/kg (500 mg) oral bd

    5 days

    Lymphadenitis (cervical)
    Mild

    S. aureus
    Group A streptococci
    Oral anaerobes

    Cefalexin 33 mg/kg (500 mg) oral tds

    7 days

    Severe

    As above

    Flucloxacillin3 50 mg/kg (2 g) IV 6H

    May require longer than 7 days

    Osteomyelitis

    Uncomplicated 

    S. aureus
    Group A streptococci

    K. kingae (partic ≤4y)
    S. pneumoniae

    Flucloxacillin3 50 mg/kg (2 g) IV 6H

    ≤4y (to incl. Kingella) Cefazolin 50 mg/kg (2g) IV 8H

    Switch to oral Cefalexin 45 mg/kg (1.5 g) oral tds once afebrile plus clinical improvement plus inflammatory markers decreasing
    3 weeks for uncomplicated cases2

    If under 5 years of age and non-Hib immunised

    As above
    plus H. influenzae type b6

    Flucloxacillin3 50 mg/kg (2 g) IV 6H and
    3rd gen cephalosporin4

    In patient with sickle cell anaemia

    As above
    plus Salmonella spp.

    Flucloxacillin3 50 mg/kg (2 g) IV 6H and
    3rd gen cephalosporin4

    3 weeks minimum

    With penetrating foot injury

    As above
    plus P. aeruginosa

    Piperacillin/Tazobactam 100 mg/kg (4 g) (Piperacillin component) IV 8H

    Surgical intervention important

    Scabies

    Sarcoptes scabiei

    Permethrin 5% cream top

    One application from neck down; leave on for minimum of 8H (usually overnight)
    May need to repeat after 7 days
    Treat whole family

    Septic arthritis

    As for osteomyelitis

    As for osteomyelitis

    3 weeks for uncomplicated cases2
    Always consider surgical drainage

    Chickenpox

    In immunocompromised or neonate 

    Shingles
    In immunocompromised

    Involving eye

    Varicella zoster virus

     

    Aciclovir 20 mg/kg IV 12H (<30 weeks gestation), 8H (>30 weeks gestation – <3 months corrected age)
    500 mg/m2 IV 8H (3 months – 12 years)
    10 mg/kg IV 8H (>12 years)

    Oral treatment (above) and Aciclovir ointment to eye 5 times per day

    7 days
    Consider zoster immunoglobulin for neonates or immunocompromised exposed to chickenpox

    Shingles in immunocompetent children does not generally require treatment

     

    SEPTICAEMIA (UNDER 2 MONTHS OF AGE)

    Infection Likely organisms Initial antimicrobials1 (maximum dose) Duration of treatment2 and other comments
    Septicaemia

    Community-acquired infection 

    Group B streptococci
    E. coli and other Gram-negative coliforms
    L. monocytogenes
    H. influenzae spp.6 plus those listed below for 'Septicaemia with unknown CSF'

    Benzylpenicillin 60 mg/kg IV
    12H (week 1 of life)
    6H (week 2–4 of life)
    4H (>week 4 of life) and
    Cefotaxime3

    Duration depends on culture results
    Premature neonates require special dosing consideration
    Also consider disseminated HSV infection, particularly under 2 weeks of age

    If abdominal source suspected

    As above
    plus Anaerobes

    Amoxicillin or Ampicillin 50 mg/kg (2 g) IV 6H and
    Gentamicin 5 mg/kg IV 24H (week 1 of life) 7.5 mg/kg IV daily thereafter and
    Metronidazole 15 mg/kg IV stat, then 7.5 mg/kg IV 8H

    If S. aureus suspected
    (eg umbilical infection)

    As above
    plus S. aureus

    Add Flucloxacillin3 50 mg/kg IV
    12H (week 1 of life)
    8H (week 1–4 of life)
    6H (>week 4 of life)

    SEPTICAEMIA (OVER 2 MONTHS OF AGE)

    Septicaemia with unknown CSF

    S. pneumoniae5
    N. meningitidis
    S. aureus
    Group A streptococci
    Gram-negatives

    Flucloxacillin3 50 mg/kg (2 g) IV 6H and
    3rd gen cephalosporin4

    Duration depends on culture results

    If central line in situ (non-oncology) or suspected MRSA infection

    As above
    plus S. epidermidis

    Substitute Flucloxacillin with Vancomycin 15 mg/kg (500 mg) IV 6H

    Septicaemia with normal CSF

    As above

    Flucloxacillin3 50 mg/kg (2 g) IV 6H and
    Gentamicin 7.5 mg/kg (320 mg) IV daily (<10 years) 6 mg/kg (560 mg) IV daily (≥10 years)

    Duration depends on culture results

    In non-Hib immunised

    As above plus
    H. influenzae type b6

    Flucloxacillin3 50 mg/kg (2 g) IV 6H and
    3rd gen cephalosporin4

    In neutropenic patient

    As above plus
    Enterococcus spp.
    P. aeruginosa

    Piperacillin/Tazobactam 100 mg/kg (4 g) (Piperacillin component) IV 6H (8H if <6 months)

    If systemic compromise or high-risk cancer treatment or inpatient onset of symptoms
    add Amikacin 22.5 mg/kg (1.5 g) IV daily (<10 years) 18 mg/kg (1.5 g) IV daily (≥10 years)

    Local protocols for fever and neutropenia may differ

    Target trough (<2 mg/L pre 3rd dose)

    If suspected C. difficile colitis add Metronidazole 7.5 mg/kg IV/oral 8H

    In neutropenic patient with potential line infection (or with severe sepsis or suspected resistant Gram-positive infection)

    As above plus Gram-positive cocci incl. S. epidermidis

    Piperacillin/Tazobactam as above and
    Amikacin as above and
    Vancomycin 15 mg/kg (500 mg) IV 6H

    Toxic shock syndrome

    S. aureus
    Group A streptococci

    As for Septicaemia above and Clindamycin 15 mg/kg (600 mg) IV 8H and
    Intravenous immunoglobulin 2 g/kg IV

    GAS contact prophylaxis: Cefalexin 25 mg/kg (1 g) oral bd for 10 days

    Notes to antimicrobial guidelines

    • These guidelines have been developed to assist doctors with their choice of initial empiric treatment
    • Except where specified, they do not apply to neonates or immunocompromised patients
    • Always ask about previous hypersensitivity reactions to antibiotic
    • The choice of antimicrobial, dose and frequency of administration for continuing treatment may require adjustment according to the clinical situation
    • The recommendations are not intended to be prescriptive and alternative regimens may also be appropriate
    • Antimicrobial recommendations may vary according to local antimicrobial susceptibility patterns; please refer to local guidelines

    1. Antimicrobial choice and dose

    • Antibiotics should be changed to narrow spectrum agents once sensitivities are known
    • Dose adjustments may be necessary for neonates, and for children with renal or hepatic impairment
    • Alternative antimicrobial regimens may be more appropriate for neonates, immunocompromised patients or others with a special infection risk (e.g. cystic fibrosis, sickle cell anaemia)
    • Resistance to antimicrobials is an increasing problem worldwide. Of particular concern is the increasing incidence of penicillin-resistant pneumococci (see footnote 5). It is important to take into account local resistance patterns when using these guidelines

    2. Duration of treatment

    • Duration of treatment is given as a guide only and may vary with the clinical situation
    • 'Step down' from intravenous to oral treatment is appropriate in many cases
    • Durations given generally refer to the minimum total intravenous plus oral treatment (See McMullan et al. Lancet Infect Dis. 2016;16:e139-52 or this PDF version)

    3. Methicillin-resistant Staphylococcus aureus (MRSA)

    • If penicillin hypersensitivity or risk of MRSA: substitute Flucloxacillin with Vancomycin 15 mg/kg (500 mg) IV 6H or Clindamycin 15mg/kg (600mg) oral tds or Trimethoprim with sulfamethoxazole (8/40 mg/mL) 4/20 mg/kg bd (320/1600 mg) oral bd
    • Risk factors for infection with MRSA:
      • Residence in an area with high prevalence of MRSA, eg Northern Territory, remote communities in northern Queensland
      • Previous colonisation or infection with MRSA (particularly recent)
      • Aboriginal and Torres Strait Islander or Pacific Islander child

    4. Third-generation cephalosporins

    • Cefotaxime: 50 mg/kg (2 g) IV 12H (week 1 of life), 6-8H (week 2-4 of life), 6H (>week 4 of life)
    • Ceftriaxone:
      • usual 50 mg/kg (2 g) IV daily;
      • severe (including meningitis and brain abscess) 100 mg/kg (2 g) IV daily or 50 mg/kg (1 g) IV 12H
      • Where possible, ceftriaxone should be avoided in neonates <41 weeks gestation, particularly if jaundiced or receiving calcium containing solutions, including TPN

    5. Pneumococci with reduced susceptibility to penicillin

    • The prevalence of invasive strains that are highly resistant to penicillin or cephalosporins in Melbourne remains low
    • A third-generation cephalosporin remains the drug of first choice for the empiric treatment of meningitis, however Vancomycin should be added if S. pneumoniae is suspected (eg Gram-positive cocci on CSF microscopy). This should be stopped if S. pneumoniae sensitivity to a third-generation cephalosporin is confirmed, as will be the case with most isolates, or once an alternative aetiology is confirmed
    • Penicillin remains the drug of first choice for the empiric treatment of non-CNS infections, such as suspected pneumococcal pneumonia, regardless of susceptibility. High doses of penicillin overcome resistance in this setting and should be used for confirmed non-CNS infection caused by penicillin-resistant pneumococci

    6. Invasive H. influenzae type b disease

    • Since the introduction of H. influenzae type b (Hib) immunisation, there has been a dramatic decline in the incidence of invasive disease
    • However, in children with potential invasive disease who are not fully immunised against Hib, therapy should include cover against Hib

    Therapeutic dose monitoring

    Gentamicin once-daily dosing

    • Once-daily administration of gentamicin is safe and effective for most patients. Certain patients, such as neonates and those with cystic fibrosis, endocarditis or renal failure, may require special dosing consideration
    • The regimen for monitoring Gentamicin levels is different for once-daily and 8, 12 or 18H dosing, and depends on renal function:
      • Normal renal function – if more than 3 doses required, the trough level (pre-dose) should be checked before the third dose and then every 3 days (target level <1 mg/L)
      • Abnormal renal function – trough levels may need to be checked earlier and more frequently (target level <1 mg/L)
      • Renal failure – levels should be checked prior to each dose and the results should be discussed with a specialist familiar with therapeutic drug monitoring before the next dose is given

    Vancomycin

    • Target trough level 10–15 mg/L for cellulitis, 15-20 mg/L for severe infection (bacteraemia, endocarditis, pneumonia, osteomyelitis, meningitis) or known high MIC

     

    Last updated July 2020