Sepsis — Antibiotic Choices for Patients with Suspected Bacterial Infections in the PICU — Clinical Pathway: Emergency Department, Inpatient and PICU

Sepsis Clinical Pathway — Emergency Department, Inpatient and PICU

Antibiotic Choices for Children > 56 days Old with Suspected Bacterial Infections in the PICU

Source Initial Empiric Therapy
Definitive therapy depends on the results of cultures and susceptibility testing
 Total Duration Comments
Oncology Patients Fever Oncology Clinical Pathway  
Community-acquired Pneumonia (CAP) Community-acquired Pneumonia Clinical Pathway — All Settings Obtain MRSA nasal culture if starting vancomycin and stop anti-MRSA therapy if negative
Hospital-acquired Pneumonia (HAP)
  • Cefepime
  • Add vancomycin if:
    • MRSA history or strong suspicion for current MRSA HAP (e.g., empyema)
    • and
    • Severe pneumonia defined as requiring new/escalated non-invasive mechanical ventilation with “high” FiO2 (> 40%) or mechanical ventilation attributable to bacterial pneumonia with lobar infiltrate
 7 days
  • Obtain MRSA nasal culture if starting vancomycin
  • Anti-MRSA therapy can generally be stopped in children who do not grow MRSA. However, prior exposure to anti-MRSA antibiotic therapy may affect culture results, so clinical judgement is required in these cases, particularly if anti-MRSA therapy has been administered ≥ 48 hours at the time of culture collection.
Ventilator-associated Pneumonia (VAP)
  • Cefepime
  • Add vancomycin if:
    • MRSA history or strong suspicion for current MRSA VAP (e.g., GPC on gram stain or empyema)
    • and
    • Significant, sustained change in respiratory support due to presumed bacterial VAP (e.g., lobar infiltrate, severe hypoxia, increased mean airway pressure)
 7 days
  • Endotracheal aspirate cultures can be used to select definitive antibiotic therapy, but positive cultures are not diagnostic of infection
  • Vancomycin can be stopped if the culture does not grow MRSA
Ventilator-associated Tracheitis (VAT)
  • Preferred: none
  • Alternative: cefepime IV or ciprofloxacin PO
  • Empiric vancomycin is generally not indicated
  • Preferred: none
  • Alternative: 5 days
 National guidelines suggest against antibiotic treatment of ventilator-associated tracheitis
Aspiration Event
  • Preferred: none
  • Develops evidence of bacterial pneumonia (generally at least 48 hours after event)
    • Community onset: ampicillin-sulbactam
    • Hospital onset: cefepime
    • Empiric vancomycin is generally not indicated
  • Preferred: none
  • For bacterial pneumonia:
    max 5-7 days
  • Most cases of aspiration cause chemical pneumonitis, not bacterial pneumonia
  • Antibiotic prophylaxis or empiric treatment at the time of the event does not prevent development of pneumonia or improve clinical outcomes
  • Cefepime provides adequate coverage for aspiration pneumonia – additional anaerobic coverage is not needed unless there is a known lung abscess
Community Onset Urinary Tract Infection (UTI) Urinary Tract Infection Clinical Pathway – All Settings  
Hospital Onset Urinary Tract Infection (UTI), or UTI with Underlying Genitourinary Anomaly or Need for Self-Catheterization
  • Cefepime IV or ciprofloxacin PO
  • If patient has a history of UTI, review prior 3 cultures and tailor empiric antibiotics to any known multidrug resistant organisms
  • Empiric vancomycin is generally
    not indicated
  • Cystitis: 3-5 days
  • Pyelonephritis: 7 days for most children
  • Longer durations (e.g., up to 14 days) may be indicated for complicated infections
  • Do not send urine cultures in children without symptoms of UTI or in children with isolated foul-smelling or cloudy urine
  • If collected, urine culture should be collected before antibiotics and by catheterization or clean catch
Fever + Central Line (PICU)
  • Cefepime
  • Add vancomycin if MRSA history
 See Treatment of a Central Line Associated Bloodstream Infection (CLABSI) in a Non-neutropenic Patient
  • Blood culture collection and antibiotic initiation should be determined by clinical suspicion for CLABSI
  • See Blood Culture Pathway
Intra-abdominal Infection
  • Community onset:
    ceftriaxone + metronidazole
  • Hospital onset: Piperacillin-tazobactam or cefepime + metronidazole if concern for concurrent CNS infection
  • Empiric vancomycin is generally not indicated
  • Duration variable based on type of infection and source control.
  • Peritonitis:
    • Discuss with ID
  • Intra-abdominal abscess:
    • Maximum of 7 days following source control
    • Longer durations may be necessary if no source control
  
Community Onset Meningitis Meningitis Clinical Pathway – All Settings  
Ventriculitis/VP Shunt Infection Cefepime + vancomycin See Treatment Recommendations for Documented Ventriculoperitoneal (VP) Shunt Infections Recommend ID Consult
No Focal Source/Unknown
  • Community onset: ceftriaxone
  • Hospital onset: cefepime
  • Consider vancomycin if MRSA history
 Recommend stopping antibiotics if no source evident after 24-48 hours and child improved Consider ID Consult if ongoing concern for infection without evident source after > 24-48 hours of antibiotics