Spinal epidural abscess in children at increased risk of infection with MRSA or gram-negative organisms

Targeted therapy is required for children with spinal epidural abscess who are at increased risk of infection with MRSA or a gram-negative organism (eg children with penetrating trauma, immunosuppression or who inject drugs). Regimens are included below for children who are at increased risk of:

  • MRSA infection – vancomycin is used as add-on therapy
  • gram-negative organisms – either ceftriaxone or cefotaxime is used as add-on therapy
  • MRSA and gram-negative organisms – vancomycin and either ceftriaxone or cefotaxime are used as add-on therapy.

Start empirical therapy for spinal epidural abscess as soon as possible. Do not delay for surgery. For children at increased risk of infection with MRSA or gram-negative organisms who have a spinal epidural abscess, as a 2- or 3-drug regimen (depending on the child’s risk), use:

flucloxacillin 50 mg/kg up to 2 g intravenously, 6-hourly. For critically ill children, use a 4-hourly dosing interval (ie 50 mg/kg up to 2 g intravenously, 4-hourly)1. See advice on modification and duration of therapy flucloxacillin

PLUS if the child is at increased risk of MRSA

vancomycin intravenously; for initial dosing, see Intermittent vancomycin dosing for young infants and children. See advice on modification and duration of therapy vancomycin

PLUS if the child is at increased risk of gram-negative organisms

1ceftriaxone (child 1 month or older) 50 mg/kg up to 2 g intravenously, daily. See advice on modification and duration of therapy ceftriaxone

OR

1cefotaxime 50 mg/kg up to 2 g intravenously, 8-hourly. See advice on modification and duration of therapy. cefotaxime

For children who have had a nonsevere (immediate or delayed) hypersensitivity reaction to a penicillin, as a 2- or 3-drug regimen, use:

cefazolin 50 mg/kg up to 2 g intravenously, 8-hourly. See advice on modification and duration of therapy cefazolin

PLUS if the child is at increased risk of MRSA

vancomycin intravenously; for initial dosing, see Intermittent vancomycin dosing for young infants and children. See advice on modification and duration of therapy vancomycin

PLUS if the child is at increased risk of gram-negative organisms

1ceftriaxone (child 1 month or older) 50 mg/kg up to 2 g intravenously, daily. See advice on modification and duration of therapy ceftriaxone

OR

1cefotaxime 50 mg/kg up to 2 g intravenously, 8-hourly. See advice on modification and duration of therapy. cefotaxime

For children who have had severe immediate2 hypersensitivity reaction to a penicillin, cefazolin and ceftriaxone or cefotaxime (at the dosage 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 who have had a severe immediate2 hypersensitivity reaction to a penicillin in whom cefazolin and ceftriaxone or cefotaxime are not used, or for children who have had a severe delayed3 hypersensitivity reaction to a penicillin, use:

vancomycin intravenously; for initial dosing, see Intermittent vancomycin dosing for young infants and children. See advice on modification and duration of therapy vancomycin

PLUS if the patient is at increased risk of gram-negative infection

ciprofloxacin 10 mg/kg up to 400 mg intravenously, 8-hourly4. See advice on modification and duration of therapy. ciprofloxacin

1 Some children with spinal epidural abscess will be critically ill. To ensure adequate drug exposure in these patients, a modified dosage of flucloxacillin is recommended. This is because pharmacokinetics may be altered in critical illness (eg because of enhanced kidney clearance or changes in volume of distribution). Once the critical illness has resolved, consider switching to the standard dosage.Return
2 Severe immediate hypersensitivity reactions include anaphylaxis, compromised airway, airway angioedema, hypotension and collapse.Return
3 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
4 Ciprofloxacin is not licensed for use in children on the basis of animal studies that showed an adverse effect on cartilage development with quinolone use; however, clinical trial data suggest that adverse musculoskeletal events are usually mild and short term, similar to those observed in adults. Ciprofloxacin can be used in children when it is the drug of choice.Return