Medication Summary
See Medical Care.
Antibiotic Agents
Class Summary
Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.
Amoxicillin (Amoxil, Biomox, Trimox)
Interferes with synthesis of cell wall mucopeptides during active multiplication, resulting in bactericidal activity against susceptible bacteria.
Ampicillin (Marcillin, Omnipen, Polycillin, Principen, Totacillin)
Bactericidal activity against susceptible organisms. Alternative to amoxicillin when unable to take medication PO. Until recently, the HACEK bacteria were uniformly susceptible to ampicillin. Recently, however, beta-lactamase–producing strains of HACEK have been identified.
Ceftriaxone (Rocephin)
Third-generation cephalosporin with broad-spectrum gram-negative activity, lower efficacy against gram-positive organisms, and higher efficacy against resistant organisms. Arrests bacterial growth by binding to one or more penicillin-binding proteins.
Cefotaxime (Claforan)
For septicemia and treatment of gynecologic infections caused by susceptible organisms. Arrests bacterial cell wall synthesis, which, in turn, inhibits bacterial growth. Third-generation cephalosporin with gram-negative spectrum. Lower efficacy against gram-positive organisms.
Gentamicin (Garamycin, I-Gent, Jenamicin)
Aminoglycoside antibiotic used for gram-negative coverage. Used in combination with both an agent against gram-positive organisms and one that covers anaerobes. Consider if penicillins or other less-toxic drugs are contraindicated, when clinically indicated, and in mixed infections caused by susceptible staphylococci and gram-negative organisms. Dosing regimens are numerous; adjust dose based on CrCl and changes in volume of distribution. May be administered IV/IM.
Vancomycin (Vancocin, Vancoled, Lyphocin)
Potent antibiotic directed against gram-positive organisms and active against Enterococcus species. Useful in the treatment of septicemia and skin structure infections. Indicated for patients who cannot receive or who have not responded to penicillins and cephalosporins or who have infections with resistant staphylococci. For abdominal penetrating injuries, it is combined with an agent active against enteric flora and/or anaerobes.
To avoid toxicity, current recommendation is to assay vancomycin trough levels after third dose drawn 0.5 h prior to next dosing. Use CrCl to adjust dose in patients diagnosed with renal impairment.
Used in conjunction with gentamicin for prophylaxis in penicillin-allergic patients undergoing gastrointestinal or genitourinary procedures.
Nafcillin (Unipen, Nafcil, Nallpen)
Initial therapy for suspected penicillin G–resistant streptococcal or staphylococcal infections.
Initially use parenteral therapy in severe infections. Change to PO therapy as condition warrants.
Because of thrombophlebitis, particularly in children or elderly patients, administer parenterally only for short term (1-2 d); change to PO route as clinically indicated.
Meropenem (Merrem)
Bactericidal broad-spectrum carbapenem antibiotic that inhibits cell wall synthesis. Effective against most gram-positive and gram-negative bacteria.
Has slightly increased activity against gram-negative organisms and slightly decreased activity against staphylococci and streptococci compared to imipenem.
Imipenem and cilastatin (Primaxin)
For treatment of multiple organism infections in which other agents do not have wide spectrum coverage or are contraindicated because of potential for toxicity.
Cefepime (Maxipime)
Fourth-generation cephalosporin with good gram-negative coverage. Similar to third-generation cephalosporins but has better gram-positive coverage.
Antipyretic Agents
Class Summary
Inhibits central synthesis and release of prostaglandins that mediate the effect of endogenous pyrogens in the hypothalamus; thus, promotes the return of the set-point temperature to normal.
Ibuprofen (Advil, Excedrin IB, Ibuprin, Motrin)
One of the few NSAIDs indicated for reduction of fever.
Acetaminophen (Aspirin Free Anacin, Feverall, Tempra, Tylenol)
Reduces fever by acting directly on hypothalamic heat-regulating centers, which increases dissipation of body heat via vasodilation and sweating.
-
Application of low-risk criteria and approach for the febrile infant: A reasonable approach for treating febrile infants younger than 3 months who have a temperature of greater than 38°C.
-
Application of algorithms for children aged 3-36 months: A reasonable approach for treating infants and young children aged 3-36 months who have a temperature of at least 39.5°C.
Tables
- Table 1. Causes of Occult Bacteremia in Neonates and Infants with a Temperature of 38°C or Higher [14, 15, 16, 17, 18]
- Table 2. Causes of Occult Bacteremia and Changes Over Time in Children Aged 3-36 Months with FWS [1, 6, 10, 12, 20, 21, 22]
- Table 3. Age, Fever, and Bacterial Infection [52]
- Table 4. Children Aged 3-36 Months - Fever and Occult Bacteremia [1, 2, 6, 8, 53]
- Table 5. Studies Evaluating the Established WBC More Than 15 per HPF Screen for Occult Bacteremia in FWS
- Table 6. Recent Studies Reevaluating WBC Count as a Screen in FWS
- Table 7. ANC as a Screen for Occult Bacteremia [1, 46]
- Table 8. Studies Reevaluating CRP level as a Screen in FWS
- Table 9. Studies Evaluating PCT level as a Screen in FWS
- Table 10. Effect of Illness Duration - PCT level as a Screen in FWS [56]
- Table 11. Low-Risk Criteria for Infants Younger than 3 Months [10, 75, 76, 77]
- Table 12. Occult Bacteremia - Relationship Between Outpatient Antibiotic Use and Complications [10, 11, 12, 22, 78]
- Table 13. Pneumococcal Bacteremia - Relationship Between Outpatient Antibiotic Use and Complications [1, 2, 10, 11, 34, 35, 42, 53, 79]
Age |
Organism* |
Positive Blood Cultures, % |
Neonates < 1 mo |
Group B Streptococcus |
73 |
Escherichia coli |
8 |
|
S pneumoniae |
3 |
|
Staphylococcus aureus |
3 |
|
Enterococcus species |
3 |
|
Enterobacter cloacae |
3 |
|
Infants aged 1-2 mo |
Group B Streptococcus |
31 |
E coli |
20 |
|
Salmonella species |
16 |
|
S pneumoniae |
10 |
|
H influenzae type b |
6 |
|
S aureus |
4 |
|
E cloacae |
4 |
|
* Also, less frequently (< 1%), Listeria species, Klebsiella species, group A Streptococcus, Staphylococcus epidermis, Streptococcus viridans, and N meningitidis |
||
Organism* |
1975-1993, % |
1993, % |
1993-1996, % |
1990 to present, % |
S pneumoniae |
83-86 |
93 |
92 |
89 |
H influenzae type b |
5-13 |
2 |
0 |
0 |
N meningitidis |
1-3 |
… |
… |
… |
Salmonella species |
1-7 |
… |
… |
… |
* Also, less frequently (< 1%), E coli, S aureus, Streptococcus pyogenes, group B Streptococcus, Moraxella species, Kingella species, Yersinia species, and Enterobacter species |
||||
Age |
Temperature, Degrees Celsius |
Rate of Bacterial Infection, % |
Neonates < 1 mo |
38-38.9 |
5 |
39-39.9 |
7.5 |
|
≥ 40 |
18 |
|
Infants aged 1-2 mo |
38-38.9 |
3 |
39-39.9 |
5 |
|
≥ 40 |
26 |
Temperature, Degrees Celsius |
Occult Pneumococcal Bacteremia, % |
Positive Blood Culture, % |
Positive Blood Culture, % |
Occult Pneumococcal Bacteremia, % |
≤ 39 |
Very low |
1.6 |
1 |
… |
39-39.4 |
1.2 |
1.6 |
5 |
… |
39.5-39.7 |
2.5 |
2.8 |
5 |
… |
39.8-39.9 |
2.5 |
2.8 |
5 |
… |
40-40.2 |
3.2 |
3.7 |
5 |
10-10.4 |
40.3-40.5 |
3.2 |
3.7 |
5 |
10-10.4 |
40.5-40.9 |
4.4 |
3.8 |
12 |
10-10.4 |
≥ 41 |
9.3 |
9.2 |
12 |
10-10.4 |
Study |
Screening Goal |
Cutoff, per HPF |
NPV, % |
PPV, % |
Fernandez Lopez, 2003 [56] |
Invasive bacterial infection* |
WBC >17 |
69 |
69 |
Pulliam, 2001 [57] |
Serious bacterial infection† |
WBC >15 |
89 |
30 |
Lacour, 2001 [58] |
Serious bacterial infection‡ |
WBC >15 |
89 |
46 |
Isaacman, 2002 [59] |
Occult bacterial infection§ |
WBC >17 |
95 |
30 |
* Culture-positive bacteremia/meningitis/sepsis/bone/joint infection; dimercaptosuccinic acid (DMSA)–positive pyelonephritis; lobar pneumonia; bacterial enteritis in infants younger than 3 months † Culture-positive bacteremia/meningitis/septic arthritis/urinary tract infection (UTI); focal infiltrate on chest radiograph ‡ Culture-positive bacteremia/meningitis/osteomyelitis; DMSA-positive pyelonephritis; lobar pneumonia § Culture-positive bacteremia/UTI; lobar pneumonia |
||||
ANC |
Sensitivity, % |
Specificity, % |
PPV, % |
NPV, % |
10,000 |
76 |
78 |
8 |
99.2 |
>7,200 |
82 |
74 |
7.5 |
99.4 |
Study |
Screening Goal |
Cutoff |
NPV, % |
PPV, % |
Lopez, 2003 [56] |
Invasive bacterial infection* |
2.8 |
81 |
69 |
Pulliam, 2001 [57] |
Serious bacterial infection† |
5 |
98 |
Not reported |
Lacour, 2001 [58] |
Serious bacterial infection‡ |
4 |
96 |
51 |
Gendrel, 1999 [61] |
Invasive bacterial infection§ |
4 |
97 |
34 |
Isaacman, 2002 [59] |
Occult bacterial infectionll |
4.4 |
94 |
30 |
* Culture-positive bacteremia/meningitis/sepsis/bone/joint infection; DMSA-positive pyelonephritis; lobar pneumonia; bacterial enteritis in infants younger than 3 months † Culture-positive bacteremia/meningitis/septic arthritis/UTI; focal infiltrate on chest radiography ‡ Culture-positive bacteremia/meningitis/osteomyelitis; DMSA-positive pyelonephritis; lobar pneumonia § Culture-positive bacteremia/sepsis/meningitis ll Culture-positive bacteremia/UTI; lobar pneumonia |
||||
Study |
Screening Goal |
Cutoff |
NPV, % |
PPV, % |
Lopez, 2003 [56] |
Invasive bacterial infection* |
0.6 |
90 |
91 |
Lacour, 2001 [58] |
Serious bacterial infection† |
1 |
97 |
55 |
Gendrel, 1999 [61] |
Invasive bacterial infection‡ |
2 |
99 |
52 |
* Culture-positive bacteremia/meningitis/sepsis/bone/joint infection; DMSA-positive pyelonephritis; lobar pneumonia; bacterial enteritis in infants younger than 3 months † Culture-positive bacteremia/meningitis/osteomyelitis; DMSA-positive pyelonephritis; lobar pneumonia ‡ Culture-positive bacteremia/sepsis/meningitis |
||||
Illness Duration |
Screening Goal |
Optimal Cutoff |
NPV, % |
PPV, % |
Any (< 12 h and >12 h) |
Invasive bacterial infection* |
0.6 |
90 |
91 |
< 12 h |
Invasive bacterial infection* |
0.7 |
90 |
97 |
*Culture-positive bacteremia/meningitis/sepsis/bone/joint infection; DMSA-positive pyelonephritis; lobar pneumonia; bacterial enteritis in infants younger than 3 months |
||||
Criterion |
Philadelphia |
Boston |
Rochester |
AAP 1993 |
Age |
1-2 mo |
1-2 mo |
0-3 mo |
1-3 mo |
Temperature |
38.2°C |
≥38°C |
≥38°C |
≥38°C |
Appearance |
AIOS*< 15 |
Well |
Any |
Well |
History |
Immune |
No antibiotics in the last 24 h; No immunizations in the last 48 h |
Previously healthy |
Previously healthy |
Examination |
Nonfocal |
Nonfocal |
Nonfocal |
Nonfocal |
WBC count |
< 15,000/μL; band-to-neutrophil ratio < 0.2 |
< 20,000/μL |
5-15,000/μL; ABC < 1,000 |
5-15,000/μL; ABC < 1,000 |
Urine assessment |
< 10 WBCs per HPF; Negative for bacteria |
< 10 WBCs per HPF; Leukocyte esterase negative |
< 10 WBCs per HPF |
< 5 WBCs per HPF |
CSF assessment |
< 8 WBCs per HPF; Negative for bacteria |
< 10 WBCs per HPF |
< 10-20 WBCs per HPF |
… |
Chest radiography |
No infiltrate |
Within reference range, if obtained |
Within reference range, if obtained |
… |
Stool culture |
< 5 WBCs per HPF |
… |
< 5 WBCs per HPF |
… |
* Acute illness observation score |
||||
Complication |
No Antibiotic Therapy, % |
Oral Antibiotic Therapy, % |
Intramuscular/Intravenous Antibiotic Therapy, % |
Persistent bacteremia |
18-21 |
3.8-5 |
0-5 |
New focal infection |
13 |
5-6.6 |
5-7.7 |
Meningitis |
9-10 |
4.5-8.2 |
0.3-1 |
Complication |
No Antibiotic Therapy, % |
Any Antibiotic Therapy, % |
Oral Antibiotic Therapy, % |
Intramuscular/Intravenous Antibiotic Therapy, % |
Persistent bacteremia |
7-17 |
1-1.5 |
2.5 |
… |
Focal infection/SBI |
9.7-10 |
3.3-4 |
… |
… |
Meningitis |
2.7-6 |
0.4-1 |
0.4-1.5 |
0.4-1 |
