Community-acquired sepsis or septic shock in children 2 months or older at risk of infection with multidrug-resistant gram-negative bacteria
For children 2 months or older with community-acquired sepsis or septic shock of unknown source who are at risk of infection with multidrug-resistant gram-negative bacteria, while awaiting results of susceptibility testing and expert advice, consider empirical therapy withAbdul-Aziz, 2024Dulhunty, 2024:
child without septic shock and not requiring intensive care support: 40 mg/kg up to 2 g, 8-hourly; administer the dose over 3 hours2
child with septic shock or requiring intensive care support: 40 mg/kg up to 2 g, administered as a loading dose over 30 minutes. After 4 hours, administer 40 mg/kg up to 2 g 8-hourly, as consecutive 8-hour infusions34
PLUS if the child has septic shock or is at increased risk of MRSA infection
vancomycin intravenously; for initial dosing, see Intermittent vancomycin dosing for young infants and children. vancomycin
Prioritise administration of meropenem, because vancomycin requires slow infusion.
For children 2 months or older in whom toxic shock syndrome is suspected5, add to the above regimen:
clindamycin 15 mg/kg up to 600 mg intravenously, 8-hourly for a minimum of 72 hours and until organ function has significantly improved6 clindamycin
PLUS
intravenous immunoglobulin (IVIg) 2 g/kg intravenously, as a single dose as soon as possible but not later than 72 hours. It is reasonable to give the dose in divided doses if it is not possible to give a single dose.
If meningitis is suspected, add to the above regimen:
dexamethasone 0.15 mg/kg up to 10 mg intravenously, preferably starting before the first dose of antibiotic, then 6-hourly7. For duration of therapy, see Overview of empirical therapy for adults and children 2 months or older with meningitis. dexamethasone
If herpes simplex encephalitis is suspected, add to the above regimens:
aciclovir intravenously, 8-hourly89 aciclovir
child younger than 5 years: 20 mg/kg or 500 mg/m2
child 5 years to 12 years: 15 mg/kg or 500 mg/m2
child older than 12 years: 10 mg/kg.
If herpes simplex encephalitis is confirmed, seek expert advice. See also Herpes simplex encephalitis for subsequent management.
If infection with carbapenem-resistant gram-negative bacteria (including carbapenemase-producing Enterobacterales) is suspected, the meropenem plus vancomycin regimen above may be given while awaiting advice from a clinical microbiologist or infectious diseases physician. Alternatively, if available, follow local guidelines.
See Managing suspected infection with multidrug-resistant gram-negative bacteria for advice on obtaining a thorough history in patients with suspected multidrug-resistant gram-negative infection, practical information on common acquired resistance mechanisms, and antimicrobials that may remain effective against multidrug-resistant gram-negative bacteria. However, this advice is not a substitute for expert advice – always consult a clinical microbiologist or infectious diseases physician.
These empirical regimens are intended for initial therapy only (up to 48 hours). Modify therapy as soon as additional information is available (eg source of infection, results of Gram stain, culture and susceptibility testing). Evaluate the appropriateness of antimicrobial therapy daily, with consideration given to the patient’s clinical status and the principles of antimicrobial stewardship.