Empirical therapy for sepsis without septic shock from a urinary tract source in children

The following regimens apply to children with sepsis from a urinary tract source who do not have septic shock (see Approach to assessing sepsis or septic shock in neonates and children).

For children with septic shock from a urinary tract source, see Empirical therapy for septic shock from a urinary tract source in children.

See Approach to managing sepsis and septic shock from a urinary tract source in children for a discussion of antibiotic choice.

For empirical therapy for sepsis without septic shock from a urinary tract source in children 3 months or older, use:

1gentamicin 7 mg/kg up to 560 mg intravenously as an initial dose¹; see Principles of aminoglycoside use for prescribing considerations and subsequent dosing gentamicin

1tobramycin 7 mg/kg up to 560 mg intravenously as an initial dose¹; see Principles of aminoglycoside use for prescribing considerations and subsequent dosing tobramycin

2ceftriaxone 50 mg/kg up to 2 g intravenously, daily ceftriaxone

2cefotaxime 50 mg/kg up to 2 g intravenously, 8-hourly. cefotaxime

For children who have contraindications or precautions that preclude aminoglycoside use, use ceftriaxone or cefotaxime (as above).

For children who have had a nonsevere (immediate or delayed) hypersensitivity reaction to a penicillin, any of the above regimens can be used.

For children who have had a severe (immediate or delayed)² hypersensitivity reaction to a penicillin, use gentamicin or tobramycin (as above) and seek expert advice.

For sepsis without septic shock from a urinary tract source in children 3 months or older who are at risk of infection with multidrug-resistant gram-negative bacteria, while awaiting results of susceptibility testing and expert advice, replace the empirical regimens above with:

meropenem 20 mg/kg up to 1 g intravenously, 8-hourly³ ⁴. meropenem

Empirical antibiotic regimens are intended for initial therapy only (up to 48 hours). Modify therapy as soon as additional information is available (eg results of Gram stain, culture and susceptibility testing of urine or blood samples). Evaluate appropriateness of antibiotic therapy daily, with consideration given to the patient’s clinical status and the principles of antimicrobial stewardship.

Once the child has clinically improved, for modification and duration of therapy, see Acute pyelonephritis in children.

¹ For children with obesity, use adjusted body weight to calculate the dose.Return

² Severe immediate hypersensitivity reactions include anaphylaxis, compromised airway, airway angioedema, hypotension and collapse. Severe delayed hypersensitivity reactions include cutaneous adverse drug reactions (eg drug rash with eosinophilia and systemic symptoms [DRESS], Stevens–Johnson syndrome/toxic epidermal necrolysis [SJS/TEN], severe blistering or desquamative rash), and significant internal organ involvement (eg acute interstitial nephritis).Return

³ Some centres use a meropenem dosage of 40 mg/kg up to 2 g intravenously, 8-hourly for children who are very unwell; however, no data are available to support the use of this dosage except in children with central nervous system infection.Return

⁴ In patients with penicillin hypersensitivity, the rate of immune-mediated cross-reactivity with carbapenems is approximately 1%; therefore, meropenem can be considered in supervised settings. However, in patients with a history of a severe cutaneous adverse reaction (eg drug rash with eosinophilia and systemic symptoms [DRESS], Stevens–Johnson syndrome/toxic epidermal necrolysis [SJS/TEN]), consider meropenem only in a critical situation when there are limited treatment options.Return