Penicillin hypersensitivity regimens for hospital-acquired sepsis or septic shock in children 2 months or older
For children 2 months or older with hospital-acquired sepsis or septic shock of unknown source who have had a nonsevere (immediate or delayed) hypersensitivity reaction to a penicillin, use:
cefepime 50 mg/kg up to 2 g intravenously, 8-hourly1 cefepime
PLUS if the child has septic shock, suspected line-related sepsis or other risk of MRSA infection
vancomycin intravenously; for initial dosing, see Intermittent vancomycin dosing for young infants and children. vancomycin
Systematic reviews suggest that adding an aminoglycoside to the empirical regimen for hospital-acquired sepsis or septic shock is associated with increased toxicity without additional clinical benefit. However, for patients with septic shock, adding an aminoglycoside may be appropriate if there is suspicion of infection with gram-negative organisms resistant to piperacillin+tazobactam. This practice is most useful if local microbiological data show a significant proportion of gram-negative organisms are susceptible to aminoglycosidesDickinson, 2011.
For children 2 months or older with hospital-acquired sepsis or septic shock of unknown source who have had a severe immediate2 hypersensitivity reaction to a penicillin, the cefepime-based regimen above can be considered if a beta-lactam antibiotic is strongly preferred (for considerations, see Severe immediate hypersensitivity: Implications of cross-reactivity between penicillins and cephalosporins).
For children 2 months or older with hospital-acquired sepsis or septic shock who have had a severe immediate2 hypersensitivity reaction to a penicillin in whom the cefepime-based regimen is not used, or who have had a severe delayed3 hypersensitivity reaction to a penicillin, as a 2-drug regimen, use:
1gentamicin 7 mg/kg intravenously for initial dose4; see Principles of aminoglycoside use for prescribing considerations and subsequent dosing gentamicin
OR
1tobramycin 7 mg/kg intravenously for initial dose4; see Principles of aminoglycoside use for prescribing considerations and subsequent dosing tobramycin
PLUS
vancomycin intravenously; for initial dosing, see Intermittent vancomycin dosing for young infants and children. vancomycin
For children 2 months or older in whom toxic shock syndrome is suspected5, add to the above regimens:
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.
For children at risk of invasive Candida infection, consider the addition of an empirical antifungal.
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.