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 septic shock from a urinary tract source in children 3 months or older, use:

1ceftriaxone 50 mg/kg up to 1 g intravenously, 12-hourly ceftriaxone

1cefotaxime 50 mg/kg up to 1 g intravenously, 6-hourly cefotaxime

PLUS with either of the above regimens

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

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

The choice of aminoglycoside should be informed by susceptibilities of expected pathogens in the local antibiogram. Amikacin is more resistant to bacterial enzymatic inactivation than gentamicin or tobramycin, so may be preferred in areas where extended-spectrum beta-lactamase (ESBL)-producing Enterobacterales (eg Escherichia coli) and carbapenemase-producing Enterobacterales (CPEs) are more prevalent. For amikacin dosing in children, see Initial aminoglycoside dosage for treating infection in children 1 month to younger than 18 years.

For children who have had a nonsevere (immediate or delayed) hypersensitivity reactionto a penicillin, use the regimen above.

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

For 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 or have contraindications or precautions that preclude aminoglycoside use, while awaiting results of susceptibility testing and expert advice, replace the empirical regimens above with:

meropenem 20 mg/kg up to 1 g intravenously, administered as a loading dose over 30 minutes. After 4 hours, administer 20 mg/kg up to 1 g 8-hourly, as consecutive 8-hour infusions³ 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.

Pharmacokinetics may be altered in children who are critically ill (eg because of enhanced kidney clearance or changes in volume of distribution). To ensure adequate drug exposure in children who have septic shock, modified dosages of ceftriaxone, cefotaxime and meropenem are recommended above. Once the critical illness has resolved, consider switching to the standard dosage – see the regimens for:

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 For children with septic shock or requiring intensive care support, administering the total daily dose of meropenem over 24 hours (as 3 consecutive 8-hourly infusions) is preferred to ensure adequate drug exposure. If this is not possible (eg the child is receiving other drugs via the same line), administer the dose (20 mg/kg up to 1 g 8-hourly) as an extended infusion over 3 hours. If a 3-hour infusion is not possible, administer over 30 minutes. For more information, see Practical information on using beta lactams: carbapenems.Return