Common bacterial infections and their

empiric treatment

Rashmi Kumar
Pediatric Intensivist
Pediatric Infectious Diseases – Oxford University
Unit Head, Pediatric Intensive Care Unit, KNH
 Objectives
• Understand modes of action of antibiotics

• Discuss impact on clinical use

• Know characteristics and side-effects of antibiotics

• Factors to consider during empirical prescription

 How do antibiotics work???
• Action specific to bacteria
• Do not target human cells

• Target:
1. Metabolic processes that do not take place in human
cells
OR
2. Molecules that are specific to bacteria
Where antibiotics act??
 Case 1
• 3-year old boy

• Fever and sore throat for one day

• No cough or runny nose

• A few tender cervical lymph nodes

 Diagnosis?
1. Swab for Rapid Antigen Testing

OR

2. Centor Criteria
 Centor criteria

Parameters Yes No Score

Age Range
3-14 years +1
15-44 years 0
>/=45 years
-1
Exudate/Swelling on tonsils +1 0

Tender swollen anterior cervical +1 0

lymph nodes

Fever >380C +1 0
Cough
+1 0
• Was found to be a useful and valid tool for diagnosis of
patients with acute pharyngitis
• What should be the optimal antibiotic option
for empirical treatment? Why?
 Phenoxymethyl Penicillin

• GAS uniformly sensitive to penicillins

• Penicillins have good tissue penetration

• Well tolerated

• Oral form available

Penicillin Half life Additional Spectrum Used for:
Family info.

Natural Very short Good Narrow N.meningitidis,

Penicillins penetration GAS, Pneumonia
into
inflammed
tissues, renal
excretion

Aminopenicillins Short Excellent oral Broader Streptococcal,

absorption. Enterococcal
infections

Anti- Short Hepatic Narrow, poor Staphylococcal

staphylococcal clearance against infections
penicillins anaerobes
Carboxy and Short half Usually Broad Intra-
Uredo life combined with spectrum abdominal
penicillins a beta- and
lactamase Pseudomonal
inhibitor infections
 Side effects…
• Rashes

• Diarrhoea, vomiting

• Hypersensitivity (allergic reactions) - 10%

• Anaphylaxis - 0.5% of population

• Rapid Antigen Test confirms Streptococcal
tonsillopharyngitis.

• History of widespread rash after antibiotics for

sore throat and middle ear infections

• Penicillin allergy??

• Way forward?
 Macrolides
Act intracellularly

Bind to ribosome subunits

Inhibit protein synthesis

 Uses of macrolides
• Pertussis

• Atypical community acquired pneumonia

• Chlamydial infections

• Legionella pneumophilla

• Helicobacter pylori

• Non-tuberculous mycobacterial infections

 Macrolides

• Active against most Gram positive and some

Gram negatives

• None of the macrolides penetrate CSF, not to

be used in treatment of meningitis
 Side-effects of macrolides

• Gastrointestinal disturbances

• Prolongation of QT interval, can result in ventricular

tachycardia

• Cholestatic hepatitis

• Hypersensitivity reactions
 Case 2
• 4-year-old child with fever

• Cough

• Mild dyspnoea

• Diagnosis?
• Empirical treatment?
We may want to cover for the commonest
cause of bacterial CAP in this age group –
S. pneumoniae
 Treatment options…
• Penicillins

• Β-lactams

• Macrolides (not at high risk of infection with

atypical organisms)

• No treatment at all
 Important…

Plan a review in a couple of days

 Case 3
• 8-year old boy with severe headache and
photophobia.

• Fever of 39.5. Looks unwell.

• Neck stiffness present.

• Antibiotics, if any?
• Third generation cephalosporin

• Added Vancomycin? If penicillin non-

susceptible pneumococcus prevalence is high

• Added Amoxicillin? If Listeria monocytogenes

infection suspected (immunosuppressed,
neonates)
 Cephalosporins

• Used in initial empirical stages of therapy

• Good choice in community acquired

meningitis and sepsis

• Active against many bacteria that cause such

serious infections
 Side effects of Cephalosporins
• Non-specific rashes

• Hypersensitivity

• C. difficile diarrhoea/colitis

• Perianal or vaginal thrush

• Leucopenia/Thrombocytopenia
CSF Gram stain shows Gram-negative diplococci.

Treatment?
• IV Ceftriaxone

• Parenteral penicillin

• Supportive care

• Prophylaxis of contacts
 Case 4
• 4-year-old girl

• 3 day history of fever and reduced appetite

• Last 2 days restarted wetting herself

• Fever 380C

• No flank tenderness

• Urine tests positive for nitrates

• Microscopy: white cell count >200 per hpf

 Organisms you might expect…
• E.coli

• Proteus spp

• Klebsiella spp

• Enterobacter spp

• Enterococcus spp

• P.aeruginosa
 Empirical antibiotics??

• Trimethoprim

• Nitrofurantoin

• Betalactam
 Side effects of Trimethoprim
• Exceedingly rare

• Photosensitivity and rashes

• Steven Johnson syndrome

• Thrombocytopenia

• Megaloblastic anemia
 Case 5
• Six year old boy with a rash

• Sick looking, tachycardic, hypotensive, flushed

• Prolonged capillary refill time

• Febrile. Temp 400 C

• A few crusted lesions show surrounding
erythema, are swollen and tender

Diagnosis??
Skin lesions
 Common organisms involved

• Group A streptococci
• Staphycoccus aureus

Diagnosis: Chicken pox with Septic shock due to

secondary skin/soft tissue bacterial infection

Empirical antibiotics??
 Antibiotics choices

• Penicillin
• Third generation Cephalosporin
• Amoxicillin Clavulanate

If MRSA suspected, Vancomycin could be added.

 Clindamycin??

• Good staphylococci and streptococci cover

• Good tissue penetration

• Anti-toxin effect through blockage of protein synthesis

• Well absorbed orally, including into bone and lungs

• CSF penetration poor

• Not active against Gram negative pathogens

 Side effects

• Unpleasant taste

• Diarrhoea, C.difficile pseudomembranous

colitis

• Temporary liver dysfunction

• Rashes and allergies

Mechanisms of antibiotic resistance
 In summary…
• More than one choice of antibiotics

• More than one approach in treating a child

• MOST IMPORTANT QUESTION: Is antibiotic

required at all??
 If answer is yes….
Questions

• What are the likely pathogens?

• What antibiotics are they likely to be sensitive to?

• Where do the antibiotics need to act?

• Any undesirable side effects?