Cardiac & Respiratory

Common Culprits: Staphylococcus aureus, other Staphylococcus species, Viridans streptococci, other streptococci, gram-negative bacilli, polymicrobial

Treatment:

• Due to penicillin-susceptible viridans streptococci and Streptococcus gallolyticus (bovis)

  • 4 Week Regimens

    1. Aqueous penicillin G 200,000 to 300,000 units/kg per 24 hours IV in 6 divided doses (maximum dose: 24 million units per 24 hours)

    2. Ampicillin 200 to 300 mg/kg per 24 hours IV divided in 4 or 6 divided doses (maximum dose: 12 g per 24 hours)

    3. Ceftriaxone 100 mg/kg per 24 hours IV in 2 divided doses or 80 mg/kg in 1 daily dose (maximum dose: 4 g per 24 hours; if dose is >2 g per 24 hours, use divided dosing every 12 hours)

    4.  Beta-lactam-intolerant patients: Vancomycin 40 mg/kg per 24 hours IV in 2 or 3 divided doses (maximum dose: 2 g per 24 hours)

       • If resistant to Penicillin G add Gentamicin 3 to 6 mg/kg per 24 hours IV in 3 divided doses for first 2 weeks

• Due to enterococcal strains susceptible to penicillin and gentamicin

  • Beta-lactam combination regimen: Ceftriaxone 100 mg/kg per 24 hours IV in 2 divided doses or 80 mg/kg in 1 daily dose (maximum dose: 4 g per 24 hours; if dose is >2 g per 24 hours, use divided dosing every 12 hours) for 6 weeks plus Ampicillin 200 to 300 mg/kg per 24 hours IV divided in 4 or 6 divided doses (maximum dose: 12 g per 24 hours) for 6 weeks

  • Aminoglycoside combination regimen: Aqueous penicillin G 200,000 to 300,000 units/kg per 24 hours IV in 6 divided doses (maximum dose: 24 million units per 24 hours) for 4 to 6 weeks or Ampicillin 200 to 300 mg/kg per 24 hours IV divided in 4 or 6 divided doses (maximum dose: 12 g per 24 hours) for 4 to 6 weeks plus Gentamicin 3 to 6 mg/kg per 24 hours IV in 2 or 3 divided doses for 4 to 6 weeks

• Due to Staphylococcus

  • Methicillin-susceptible strains

    1. Nafcillin or oxacillin 200 mg/kg per 24 hours IV (maximum dose: 12 g per 24 hours) in 4 or 6 divided doses for 4 to 6 weeks

    2. Cefazolin 100 mg/kg per 24 hours IV (maximum dose: 6 g per 24 hours) in 3 divided doses for 4 to 6 weeks

  • Methicillin-resistant strains

    1. Vancomycin 40 mg/kg per 24 hours IV (maximum dose: 2 g per 24 hours unless levels are inappropriately low) in 2 or 3 divided doses for 6 weeks

• Due to Gram-negative organisms

  • Monotherapy

    1. Ceftriaxone 100 mg/kg per 24 hours IV in 2 divided doses, or 80 mg/kg in 1 daily dose (maximum dose: 4 g per 24 hours; if dose is >2 g per 24 hours, use divided dosing every 12 hours) for 4 weeks

    2. Cefotaxime 200 mg/kg per 24 hours IV in 4 divided doses (maximum dose: 12 g per 24 hours) for 4 weeks

  • Combination therapy

    1. Ampicillin 200 to 300 mg/kg per 24 hours IV divided in 4 or 6 divided doses (maximum dose: 12 g per 24 hours) for 4 weeks plus Gentamicin 3 to 6 mg/kg per 24 hours IV in 3 divided doses for 4 weeks

Special Considerations: Inpatient most likely, consult with an infectious disease specialist (especially for Enterococci)

Common Culprit: Bordetella pertussis

First and Second line oral treatment by age group:

• <1 month

  1. Azithromycin 10 mg/kg per day in a single dose for 5 day

• 1 through 5 months

  1. Azithromycin 10 mg/kg per day in a single dose for 5 days

  2. Erythromycin 40 mg/kg per day in 4 divided doses for 14 days

  3. Clarithromycin 15 mg/kg per day in 2 divided doses for 7 days

• Infants (aged ≥6 months) and children

  1. Azithromycin 10 mg/kg in a single dose on day 1 (maximum: 500 mg); then 5 mg/kg per day (maximum: 250 mg) on days 2 through 5

  2. Erythromycin 40 mg/kg per day in 4 divided doses for 7 to 14 days (maximum: 2 g per day)

  3. Clarithromycin 15 mg/kg per day in 2 divided doses for 7 days (maximum: 1 g per day)

• Adults

  1. Azithromycin 500 mg in a single dose on day 1 then 250 mg per day on days 2 through 5 (preferred in pregnant patients)

  2. Erythromycin 2 g (base) per day in 4 divided doses for 7 to 14 days

  3. Clarithromycin 15 mg/kg per day in 2 divided doses for 7 days (maximum: 1 g per day)

Special Considerations: Alternative agent to macrolides is trimethoprim-sulfamethoxazole (cotrimoxazole)

Common Culprits: S. pneumoniae (most common), M. pneumoniae (more common among children ≥5 years), C. pneumoniae ( more common in older children and young adults), H. influenzae type b (Hib), nontypeable H. influenzae, Moraxella catarrhalis, S. aureus, S. pyogenes, and atypical bacteria

Outpatient treatment by age:

• One to six months

  1. Infants younger than three to six months of age with suspected bacterial CAP or who are hypoxemic (oxygen saturation <90 percent in room air at sea level) should be admitted to the hospital for empiric therapy

  2. C. trachomatis ("afebrile pneumonia of infancy") infection if afebrile and not hypoxic: Azithromycin 20 mg/kg per day given orally once daily for three days

  3. Bordetella pertussis: See Pertussis section

• Six months to five years

  1. Suspect viral

  2. Amoxicillin 90 mg/kg per day in 2 or 3 divided doses (MAX 4 g/day) for 5 days

  3. Amoxicillin-clavulanate 90 mg/kg per day of the amoxicillin component in 2 or 3 divided doses (MAX 4 g/day amoxicillin component) for 5 days

  4. Levofloxacin 16 to 20 mg/kg per day in 2 divided doses (MAX 750 mg/day) for 5 days 

     • PCN allergy option

  5. Clindamycin 30 to 40 mg/kg per day in 3 or 4 divided doses (MAX 1.8 g/day) for 5-10 days 

     • PCN allergy option

  6. Linezolid 30 mg/kg per day in 3 divided doses (MAX 1.8 g/day) for 10 days 

     • PCN allergy option

• ≥5 years AND Mycoplasma pneumoniae or Chlamydia pneumoniae

  1. Azithromycin 10 mg/kg on day 1 followed by 5 mg/kg daily for 4 more days (MAX 500 mg on day 1 and 250 mg thereafter)

  2. Clarithromycin 15 mg/kg per day in 2 divided doses for 10 days (MAX 1 g/day)

  3. Erythromycin 40 to 50 mg/kg per day in 4 divided doses for 10 days (MAX 2 g/day as base, 3.2 g/day as ethylsuccinate)

  4. Doxycycline 4 mg/kg per day in 2 divided doses for 10 days (MAX 200 mg/day)

  5. Levofloxacin 8 to 10 mg/kg once daily for children 5 to 16 years (MAX 500 mg/day); 500 mg once daily for children ≥16 years for 5 days 

  6. Moxifloxacin 400 mg once daily for 5 days (≥18 years)

• ≥5 years Typical Bacterial

  1. Amoxicillin 90 mg/kg per day in 2 or 3 divided doses (MAX 4 g/day) for 5 days

  2. Levofloxacin 8 to 10 mg/kg once daily for children 5 to 16 years (MAX 750 mg/day); 750 mg once daily for children ≥16 years for 5 days 

     • PCN allergy option

  3. Clindamycin 30 to 40 mg/kg per day in 3 or 4 divided doses (MAX 1.8 g/day) for 5-10 days 

     • PCN allergy option

  4. Linezolid 30 mg/kg per day in 3 divided doses (MAX 1.8 g/day) for children <12 years; 20 mg/kg per day divided in 2 doses (MAX 1.2 g/day) for children ≥12 years  for 10 days 

     • PCN allergy option

Special Considerations:

• Aspiration pneumonia

  1. Amoxicillin-clavulanate 40 to 50 mg/kg per day in 2 or 3 divided doses (MAX 1.75 g/day amoxicillin component) for 5 days

  2. Clindamycin 30 to 40 mg/kg per day divided in 3 or 4 doses (MAX 1.8 g/day) for 5-10 days 

     • PCN allergy option

  3. Moxifloxacin 400 mg once daily for 5 days (for ≥18 years) 

     • PCN allergy option

This is an Emergency Department condition, will often present with stridor and dyspnea

Common Culprits: S. aureus (most common), S. pneumoniae, group A Streptococcus (Streptococcus pyogenes), alpha-hemolytic streptococci, Moraxella catarrhalis, Haemophilus influenzae

Treatment:

Vancomycin 15 mg/kg per dose every 6 to 8 hours (maximum daily dose: 4 g) PLUS

• • 1. Ceftriaxone 50 mg/kg per dose every 12 to 24 hours (maximum daily dose: 2 g) 

    2. Cefotaxime (if available) 150 to 200 mg/kg per day in 4 divided doses (maximum dose 2 g) 

    3. Ampicillin-sulbactam 150 to 200 mg/kg (of ampicillin component) per day in 4 divided doses (maximum daily dose: 8 g)

  • OR for patients with potential severe hypersensitivity to beta-lactam antibiotics (eg, penicillin, cephalosporin):

    1. Levofloxacin (6 months to 5 years): 10 mg/kg per dose every 12 hours (maximum daily dose: 500 mg), ≥5 years: 10 mg/kg per dose once daily (maximum daily dose: 500 mg) 

    2. Ciprofloxacin 20 to 30 mg/kg per day in 2 divided doses (maximum daily dose: 800 mg)

Special Considerations:

In patients with tracheostomy tubes tracheal aspirate should be obtained and antimicrobial therapy chosen as a result of the Gram stain. For empiric therapy amoxicillin-clavulanate, quinolones (eg, ciprofloxacin or levofloxacin), or clindamycin are all good options. A treatment course of three to seven days is generally sufficient for an uncomplicated course of infection.

Common Culprit: Mycobacterium tuberculosis

Treatment by age:

• <3 months: 6 month regimen

  • Isoniazid (10mg/kg, max dose 300mg), rifampin (15 to 20 mg/kg, max dose 600mg), pyrazinamide (35mg/kg, max dose 600mg), and ethambutol (20 mg/kg, max dose 1 g) for eight weeks, followed by isoniazid and rifampin for 16 weeks

• 3 months to 11 years: 4 month regimen

  • Isoniazid (10mg/kg, max dose 300mg), rifampin (15 to 20 mg/kg, max dose 600mg), pyrazinamide (35mg/kg, max dose 600mg), and ethambutol (20 mg/kg, max dose 1 g) for eight weeks, followed by isoniazid and rifampin for 8 weeks

• 12 to 16 years (over 40kg): Rifapentine-moxifloxacin-based regimen 

  • Isoniazid (300mg), pyrazinamide (dosing based on weight; ≥40 to 55 kg: 1 g, ≥55 to 75 kg: 1.5 g, >75 kg: 2 g), rifapentine (1200mg), moxifloxacin (400mg) for eight weeks, followed by isoniazid, rifapentine, and moxifloxacin for 9 weeks

Special Considerations:

Children for whom an empiric treatment regimen for drug-resistant disease may be warranted include:

• Children with treatment failure (acid-fast bacilli sputum culture positive after four months of therapy, assuming drug sensitivity testing is not available, or poor response to traditional therapy)

• Children with relapse (recurrent TB after apparent cure)

• Children with exposure to an individual with infectious drug-resistant pulmonary TB

• Children with residence in or travel to a region with high prevalence of drug-resistant TB