1. Principles of antibiotic therapy in paediatrics
Dr. György Fekete

2. 1. What is the reason? Indication?
Antibiotics
1. What is the reason? Indication?
- local infection
- empiric and targeted teatment
- fever + general symptoms (CRP, WBC count and smear, etc.)

3. 2. Previous microbiological investigations?
- throat
- urine
- haemoculture
- cerebrospinal fluid

4. 3. What is the potential (bacterial) cause of infection?
- age (newborn, infant, toddler…)
- medical procedure, hospitalisation
- immune deficiency
- organ damage (spleen, liver, kidney)

5. Neonatal sepsis /meningitis
Focal infection: pneumonia, RDS
Group B streptococci, E. coli, other Gram-negative rods, Listeria monocytogenes
Th: Ampicillin+ gentamicin
third generation cephalosporin instead of aminoglycoside

6. Bacterial meningitis in children, 2months to 12 yrs
S. pneumoniae, N. meningitidis,
(H. influenzae type b)
Therapy: - cefotaxime / ceftriaxone vancomycine
- 3. generation cephalosporines
(Cefotaxime, Ceftriaxone)

7. 4. Which antibiotic will be optimal? First choice?
- data of bacterial resistance
- site of infection – penetration?
- side effects?
- bactericide effect
- administration: 1x / day
- not expensive

8. 5. Any combination is appropriate?
- nosocomial infection
- sepsis
- abdominal and pelvic infections
- endocarditis
- empiric treatment
- active tuberculosis

9. Active tuberculosis Treatment: INH, rifampin, pyrazinamide
Ethambutol, ethionamide

10. 6. Metabolism, excretion? - kidney, liver (monitoring)
- renal: aminoglycosides
- liver:erythromycin, clindomycin
7. Mode of administration
- iv, oral
- „switch”

12. 8. Dosage ?
9. Changing of antiobiotic drug? Indications?
10. How long should we treat?
- Preterm and newborn babies need antibiotic therapy of longer duration (sepsis, bacterial meningitis, etc.)

13. Antimicrobial prophylaxis
Neonatal conjunctivitis
Chlamydia trachomatis
0,5% erythromycin topically
Neisseria gonorrhoeae
1% silver nitrate or

14. Antimicrobial prophylaxis
Splenectomy / asplenia
Str. pneumoniae
Penicillin

15. Resistant clones of microorganisms
Str. pneumoniae
Staph. aureus
Virulent
Serious infections
Overuse of antibiotics
Viral infections
Broad spectrum antimicrobial agents

16. Antibiotic management of Staphylococcus aureus infections in US Children’s hospitals, 1999-2008
Trends in antibiotic management for S. aureus infections, hospitalized children
The use of vancomycin, clindamycin, linezolid, trimethoprim-sulfamethoxazole, cefazolin, and oxacillin/nafcillin were examined for percentage use and days of therapy per 1000 patient- day
patients had a discharge diagnosis for S. aureus infection
The incidence of methicillin-resistant S. aureus (MRSA) infections increased 10-fold (2 to 21 cases per 1000 admissions), methicillin- susceptible infection rate remained stable
Clindamycin showed the greatest increase: 21% in 1999 and 63% in 2008
Importance of continuous monitoring of local S. aureus susceptibility patterns
Herigon J.C et al. Pediatrics 2010, 125:1267

17. Broad - spectrum antimicrobial agents
Drastic changes in bowel flora
Bleeding disorders
Emergence of resistant organisms
Superinfections: yeasts, enterococci

18. Local (hospital) microbiological laboratory
Knowing the prevalence of antibiotic – resistant organisms in a particular community (nursery) is helpful in choosing the first-line antibiotic regimens

19. Specific therapeutic values
Vancomycin: methicillin-resistant staphylococci
Metronidazole: anaerobic infections
Ceftazidine: Pseudomonas aeruginosa
Trimethoprime+ sulfamethoxazole: shigellosis, salmonellosis, Pneumocysis carinii ( pentamidine)

24. Test of efficacy= patient’s response
No respond to seemingly appropriate therapy: reassessment is needed!
In some infections additional supportive treatment ( surgical) is necessary

25. Tonsillitis, tonsillopharyngitis
Streptococcus pyogenes : Penicillin for 10 days
Penicillin allergy: macrolid antibiotics
Non- Streptococcus origin: amoxicillin, amoxicillin+ clavulanic acid, macrolids, cephalosporin antibiotics

26. Anaerobic infections Oropharynx, gastrointestinal tract, vagina, skin
Gram- negative nonsporulating rods: Bacteroides, Fusobacterium
Gram-positive nosporulating rods: Eubacterium, Propionibacterium

27. Anaerobic infections
Neonates: prolonged rupture of membranes, amnionitis, obstetric difficulties
Peritonitis, appendicitis
Aspiration pneumonia with lung abscess
Orofacial infections
Brain abscess

28. Periodontal infection („trench mouth”) Acute Necrotizing Ulcerative Gingivitis ( ANUG)
Periapical abscesses
Anaerobic osteomyelitis of the mandible /maxilla

29. Vincent stomatitits
Ulcers covered by brown/grey, foul-smelling exudate

31. Ludwig angina
Acute cellulitis of the sublingual and submandibular spaces
Rapid spread
Edema of the tongue and airway

32. Anaerobic infections/ treatment
Cefoxitin, amoxicillin/ clavulanate, clindamycin
Metronidazole
Cefotetan
Imipenem, merapenem
Piperacillin, tazobactam

37. CEPHALOSPORIN ANTIBIOTICS
1. generation drugs
Cefazolin (Kefzol) does not cross the blood- brain barrier. No use for initial th. of sepsis / meningitis
Cefalexin (Keflex. Ospexin)
Cefadoxil (Duracef)

38. 2. generation drugs
Cefamandol (Mandokef)
Cefuroxim (Zinnat, Zinacef)
Cefoxitin (Mefoxin)
Cefaclor (Ceclor)

39. 3. generation drugs
Cefotaxim e (Claforan)
Ceftriaxone (Rocephin)
Cefoperazon (Cefobid)
Ceftazidim ((Fortum)
Cefixim (Suprax)
Ceftibuten (Cedax)

40. 4. generation drug
Cefepim (Maxipime)

41. Presentation 7-year-old boy
3 weeks of headache refractory to acetaminophen, 1 day of altered mental status, diplopia, photophobia
Physical examination: he is difficult to arouse and is confused. He vomits once in the ED.
No skin lesions, signs of meningeal irritation, or joint swelling. Bilateral papilledema and photophobia
WBC 15.8x109/L, 85% segmented neutrophils. Lumbar puncture, CSF sent for Lyme titers, serum antibodies: positive for IgG and negative for IgM
Th: 28 days IV ceftriaxone (100 mg/kg per day)
Additional questioning:2 months prior he had erythema migrans, was diagnosed as having Lyme disease, and was treated with 21 days of cefuroxime

42. PENICILLIN
Penicillin G V Streptococcus
procain-penicillin Str. pneumoniae

43. METHICILLIN
Oxacillin
Staphylococcus aureus
Nafcillin

44. AMINOPENICILLIN
(ampicillin , amoxicillin) Streptococcus B
Str. pneumoniae
Listeria

45. amoxicillin+clavulanic acid)
AMINOPENICILLIN
beta+-lactamase respiratory , inhibitor urinary tract infections
(ampicillin+sulfactam,
amoxicillin+clavulanic acid)

46. UREIDOPENICILLIN
mezlocillin, piperacillin
(+beta-lactamase inhibitor as well)
piperacillin/tazobactam
Severe systemic infections

47. Tetracyclines Contraindicated before the age of 10 yrs! Good effect:
Chlamydia, Mycoplasma, Actinomyces, Lyme disease, pelvic infections, urethritis, brucellosis
Contraindicated before the age of 10 yrs!

48. ANTIBIOTIC DRUGS
Active ingredient Product
Amoxicillin Aktil, Augmentin
+ clavulanic acid
Ampicillin Ospamox, Penstabil,
Pentrexyl

49. Active ingredient Product
Ampicillin Unasyn
+Sulbactam
Azithromycin Sumamed
Azlocillin Securopen

50. Active ingredient Product
Cefadroxil Duracef
Ceftazidime Fortum
Ceftriaxon Rocephin
Cefixim Suprax

51. Active ingredient Product
Cefepime Maxipime
Ceftibuten Cedax
Cefoperazon Cefobid
Cefotaxim Claforan

52. Active ingredient Product
Cefuroxim Zinacef, Zinnat
Clarithromycin Klacid
Clindamycin Dalacin C
Ciprofloxacin Ciprobay, Cifran,
Supplin

53. Active ingredient Product
Imipenem Tienam
+ cilostatin
Josamycin Wilprafen
Meropenem Meronem
Metronidazol Klion

54. Active ingredient Product
Mezlocillin Baypen
Netilmicin Netromycine
Penicillin Maripen, Ospen,
Vegacillin

55. Active ingredient Product
Sulfamethoxazol Sumetrolim,
+trimethoprim Bactrim, Cotrimel
Teicoplanin Targocid
Tobramycin Brulamycin
Vancomycin Vancocyn