Medication Summary

Immediately administer empiric broad-spectrum antibiotics when managing a pediatric small bowel obstruction in which compromised bowel with necrosis or perforation is suspected. Infants with necrotizing enterocolitis are treated with antibiotics regardless of whether or not their disease progresses to requiring surgery. In addition, perioperative prophylactic antibiotics should be given whenever there is reasonable expectation of intraoperative entry into the gastrointestinal tract (making the wound classification at minimum "clean contaminated"). The exact antibiotics utilized vary between institutions based upon local antibiograms and provider preferences.

Class Summary

Antibiotic therapy must cover all likely pathogens in the clinical setting.

Clindamycin (Cleocin)

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Clindamycin is a lincosamide that is useful in treating serious skin and soft tissue infections caused by most staphylococcal strains. It is also effective against aerobic and anaerobic streptococci, except enterococci.

Clindamycin inhibits bacterial protein synthesis by inhibiting peptide chain initiation at the bacterial ribosome, where it preferentially binds to the 50S ribosomal subunit, inhibiting bacterial growth.

Metronidazole (Flagyl)

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Metronidazole is an imidazole, ring-based antibiotic that is active against various anaerobic bacteria and protozoa. It is used in combination with other antimicrobial agents (although it is used alone in Clostridium difficile enterocolitis).

Aztreonam (Azactam)

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Aztreonam is a monobactam that inhibits cell wall synthesis during bacterial growth. It is active against gram-negative bacilli. Aztreonam is effective against aerobic gram-negative organisms.

Cefoxitin (Mefoxin)

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Cefoxitin is a second-generation cephalosporin that is used to treat infections caused by susceptible gram-positive cocci and gram-negative rods. It is effective against aerobic and anaerobic gram-negative organisms.

Cefotetan

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Cefotetan is a second-generation cephalosporin that is used to treat infections caused by susceptible gram-positive cocci and gram-negative rods. It is not approved by the US Food and Drug Administration (FDA) for use in children.

Imipenem and cilastatin (Primaxin)

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This agent is effective against aerobic and anaerobic gram-negative organisms.

Ampicillin (Ampi, Omnipen, Penglobe)

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Ampicillin is a broad-spectrum penicillin. It interferes with bacterial cell wall synthesis during active replication, causing bactericidal activity against susceptible organisms. Ampicillin is an alternative to amoxicillin when patients are unable to take medication orally.

Ticarcillin and clavulanate potassium (Timentin)

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This agent inhibits the biosynthesis of cell wall mucopeptide and is effective during the active growth stage. It is an antipseudomonal penicillin plus a beta-lactamase inhibitor, that provides coverage against most gram-positive, gram-negative, and anaerobic organisms.

Piperacillin/tazobactam (Zosyn)

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The combination of piperacillin/tazobactam comprises an antipseudomonal penicillin plus a beta-lactamase inhibitor. This agent inhibits biosynthesis of cell wall mucopeptide synthesis by binding to one or more of the penicillin-binding proteins and is effective during active-multiplication stage.

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Media Gallery

Pediatric Small Bowel Obstruction. Small bowel obstruction is visible on a plain radiograph caused by intussusception in a 5-month-old patient.
Pediatric Small Bowel Obstruction. This barium enema study reveals a coil spring appearance caused by the tracking of barium around the lumen of the edematous intestine in intussusception.
Pediatric Small Bowel Obstruction. This image reveals small bowel obstruction caused by an incarcerated inguinal hernia in a 2-month-old infant with bilateral inguinal hernias as well as an umbilical hernia.
Pediatric Small Bowel Obstruction. This radiograph depicts the double-bubble sign characteristic of duodenal atresia.
Pediatric Small Bowel Obstruction. An upper gastrointestinal contrast study demonstrates a jejunal atresia with a proximal dilated atretic bowel and lack of passage of contrast material into the distal small bowel.
Pediatric Small Bowel Obstruction. This is a surgical photograph of the patient in the previous image, depicting the proximal dilated atretic jejunum.
Pediatric Small Bowel Obstruction. An upper gastrointestinal contrast study shows a malrotation with lack of a normal C-shaped duodenum and the small bowel "hanging" on the right side of the abdomen.
Pediatric Small Bowel Obstruction. This imaged is a contrast enema study showing an abnormally located cecum in a patient with malrotation.
Pediatric Small Bowel Obstruction. The surgical photograph shows necrotic bowel in a patient with midgut volvulus.
Pediatric Small Bowel Obstruction. Necrotic bowel is shown after surgical reduction of an intussusception.
Pediatric Small Bowel Obstruction. The surgical photograph depicts a transition zone in a patient with small bowel obstruction.
Pediatric Small Bowel Obstruction. An incarcerated left inguinal hernia is noted.
Pediatric Small Bowel Obstruction. This photograph reveals a mesocolic hernia.
Pediatric Small Bowel Obstruction. The surgical image depicts a laparotomy on a 7-month-old girl with ileocolic intussusception.
Pediatric Small Bowel Obstruction. The surgical image depicts a laparotomy on a 2-day-old female patient with congenital small bowel obstruction. A type I jejunal atresia without mesenteric gap and a grossly dilated proximal intestine is seen.
Pediatric Small Bowel Obstruction. A barium enema study on a 1-year-old male patient depicts an ileocolic intussusception.
Pediatric Small Bowel Obstruction. The clinical photograph of a 5-month-old male patient reveals characteristic currant-jelly stools due to intussusception.
Pediatric Small Bowel Obstruction. The plain abdominal film on a 3-day-old newborn depicts the classic double-bubble sign for duodenal atresia.
Pediatric Small Bowel Obstruction. This contrast-enhanced upper gastrointestinal film shows a duodenal atresia in a 2-day-old newborn.
Pediatric Small Bowel Obstruction. The surgical photograph is that of a 3-year-old male patient with an obstructive, noncommunicating ileal duplication.
Pediatric Small Bowel Obstruction. This plain abdominal film was obtained in a 6-year-old male patient with MRCP (mental retardation and cerebral palsy) and an organo-axial gastric volvulus. Note the grossly dilated and obstructed stomach. A gastrostomy feeding tube can be seen in place. Surgical staples from a previous laparoscopic fundoplication are seen near the diaphragmatic crura.
Pediatric Small Bowel Obstruction. This is a surgical photograph of an 8-month-old patient with ileocolic intussusception.
Pediatric Small Bowel Obstruction. The plain abdominal film of a premature baby born at 28 weeks of gestation reveals necrotizing enterocolitis. Note the "railroad sign" (pneumatosis intestinalis) in the hepatic flexure and "soap bubbles" in the descending colon.
Pediatric Small Bowel Obstruction. This clinical image of a micro-premature baby boy shows discoloration on the right lower quadrant of the abdomen due to intestinal perforation secondary to necrotizing enterocolitis. An umbilical catheter is in place.
Pediatric Small Bowel Obstruction. A plain abdominal film of a premature baby girl with necrotizing enterocolitis is shown. Note the air in the biliary tree and the grossly dilated bowel.
Pediatric Small Bowel Obstruction. This is a surgical photograph of a 1-year-old male patient who previously underwent a right radical nephrectomy for Wilms tumor. He presented to the emergency department with signs of a mechanical small bowel obstruction. A transition zone is clearly seen at the point where the small bowel is trapped on an internal hernia through a mesenteric gap.
Pediatric Small Bowel Obstruction. This sonogram reveals intussusception in a 9-month-old male patient.
Pediatric Small Bowel Obstruction. The surgical photograph was obtained in an 8-month-old boy with intussusception. The surgeon's finger is inserted into the intussusceptum, and the intussuscipiens is seen entering the distal bowel. No lead point was identified.
Pediatric Small Bowel Obstruction. The surgical photograph depicts loops of bowel passing through a mesenteric defect. The bowel segment proximal to the obstruction is dilated, purplish, distended, and hypoperistaltic. The bowel distal to the obstruction is decompressed and normal-looking.
Pediatric Small Bowel Obstruction. The surgical photograph was obtained in a newborn with a type IIIa jejunal atresia. Note the dilated proximal bowel pouch, the mesenteric V-shaped defect, and the thin, nondilated distal jejunum.
Pediatric Small Bowel Obstruction. The surgical photograph depicts a Meckel diverticulum.
Pediatric Small Bowel Obstruction. This surgical photograph was obtained from a newborn with type IIIb (“apple peel” or “Christmas tree”) atresia. Note the shortened distal small bowel coiled around its mesentery.

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Author

Pranit Chotai, MD Assistant Professor of Surgery, Division of Transplant Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and UH Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine

Pranit Chotai, MD is a member of the following medical societies: American College of Surgeons, American Pediatric Surgical Association, American Society of Transplant Surgeons, Americas Hernia Society, Association for Academic Surgery, Pediatric Trauma Society, Society of Asian Academic Surgeons, Tennessee Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Kyle J Van Arendonk, MD, PhD Assistant Professor, Department of Surgery, Division of Pediatric Surgery, Children’s Hospital of Wisconsin, Medical College of Wisconsin

Kyle J Van Arendonk, MD, PhD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American College of Surgeons, American Pediatric Surgical Association, Association for Academic Surgery, International Pediatric Endosurgery Group, Midwest Pediatric Surgery Consortium, Phi Beta Kappa, Surgical Outcomes Club, Wisconsin Surgical Society

Disclosure: Nothing to disclose.

Chief Editor

Carmen Cuffari, MD Associate Professor, Department of Pediatrics, Division of Gastroenterology/Nutrition, Johns Hopkins University School of Medicine

Carmen Cuffari, MD is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition, Royal College of Physicians and Surgeons of Canada

Disclosure: Received honoraria from Prometheus Laboratories for speaking and teaching; Received honoraria from Abbott Nutritionals for speaking and teaching. for: Abbott Nutritional, Abbvie, speakers' bureau.

Additional Contributors

Jaime Shalkow, MD, FACS Pediatric Surgical Oncologist, ABC Cancer Center; Associated Researcher, Anahuac University, Mexico

Jaime Shalkow, MD, FACS is a member of the following medical societies: American College of Surgeons, International Society of Paediatric Surgical Oncology, International Society of Pediatric Oncology, Latin American Pediatric Surgical Oncology Group, Mexican Association of Pediatric Surgery, Mexican Society of Oncology

Disclosure: Nothing to disclose.

Adrian Florens, MD, FAAP Neonatologist, KIDZ Medical Services; Clinical Instructor of Pediatrics, Florida International University and Florida Atlantic University

Adrian Florens, MD, FAAP is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Joyce Vazquez-Braverman, MD Instructor of ACLS, BLS, and Heartsavers, American Heart Assocation

Joyce Vazquez-Braverman, MD is a member of the following medical societies: American College of Physicians

Disclosure: Nothing to disclose.

Eduardo Fastag Guttman, MD Medical Assistant Physician, Anesthesiology Integral

Disclosure: Nothing to disclose.

Issac Octavio Vargas Olmos Universidad Anahuac, Mexico

Disclosure: Nothing to disclose.

Acknowledgements

Jose Asz, MD Professor of Embryology, Assistant Professor of Surgery and Pediatrics, Faculty of Medicine, Universidad Nacional Autonoma de Mexico; Consulting Staff, Department of General Surgery, National Institute of Pediatrics, Mexico