Rational Use of

Antibiotics in Neonates
and Children
Dr. Nandkishor S. Kabra
DM (Neonatology), MD (Ped), DNB (Ped),
MNAMS, MSc (Clinical Epidemiology, McMaster University,
Canada)
Consultant Neonatologist and Director, NICU,
Surya Hospital, Santacruz (W), Mumbai
1881-1955
 1945: Noble Prize Lecture
“It is not difficult to make microbes resistant to
penicillin in the laboratory by exposing them to
concentrations not sufficient to kill them, and
the same thing has occasionally happened in
the body…there is the danger that the ignorant
man may easily under-dose himself and by
exposing his microbes to non-lethal quantities
of the drug make them resistant.”
1998 2004
2006
2007
2011
2014
2016
2016
 2016

 88636 live births, 14779 admissions in NICU, 1249 recruited in

concurrent study,13530 included in analysis (July 2011- Feb 2014)
 Sepsis: 14.3%,
 Culture Positive Sepsis 6.2%
 EOS vs. LOS
 EOS 1351(83%) of total sepsis episodes
 Gram negative isolates 645/1005 (64%) : Acinetobacter (22%),
Klebsiella (17%), E Coli (14%)
 2016

 MDR: Acinetobacter (181/222; 82%), Klebsiella (91/169; 54%),

E Coli (52/137; 38%).
 MRCONS (85/140; 61%)
 MRSA (43/114; 38%)
 Deaths attributable to sepsis 505/2106 (24%)
 Golden Rules 2005

1. Acute infections always presents with fever. In acute

illness, absence of fever does not justify use of
antibiotics.
2. Infection is the most common cause of fever in office
practice, though not always bacterial infection. Viral
infection should not be treated with an antibiotic.
3. Clinical differentiation is possible between bacterial and
viral infection, most of the times.
 Golden Rules 2005

4. Chronic infection may not be associated with fever and

diagnosis is difficult.
5. Choose a single oral antibiotic, either covering gram-
positive or gram-negative organisms, as per site of
infection and age of the patient. Combination of two
antibiotics is justified in serious bacterial infection without
proof of specific organism and these may be administered
intravenously.
Therapeutic usage of antibiotics
occurs in 3 settings:
 Definitive: Proven pathogen with or without
antibiotic susceptibility available.
 Empirical: Infection most likely but exact organism
and sensitivity not known.
 Pre-emptive: Infection probable but not proved.
Diagnosis of Acute Bacterial Infections
1. Based on clinical features and supported by
laboratory investigations
2. It can be divided as follows according to the age of
presentation as certain organisms are typically seen
in that age group
1. 0 to 3 months
2. 3 months to 3 years
3. 3 years onwards
 0- 3 Months
Signs/Symptoms
1. Non Reassuring Fetal Status

2. Tachycardia

3. Respiratory distress or apnea in neonate

4. Feeding difficulty or intolerance

5. Irritability

6. Altered sensorium
 Unique Features
Newborns are more susceptible due to
 Immunological immaturity

 Coexisting conditions complicate diagnosis

and treatment
 Signs and symptoms are varied in nature

 Maternal infections may remain undiagnosed

which is the source of fetal infection

 Infections can be acquired from the mother

 Prolonged NICU stay

 0- 3 Months
Common Causative Organisms
• Klebsiella, E. Coli, Acinetobacter,
Pseudomonas, Eneterococcus Faecalis,
Enterobacter, Serratia, Citrobacter

• Staphylococcus Aureus , Candida

• Very rarely- H. Influenzae, Pneumococci and
Meningococci
 Treatment

 Must have low threshold to start antibiotics

 Early Onset Sepsis
 Late Onset Sepsis
 3 Months to 3 Years
Common Organisms
H. Influenzae Type B, Streptococcus Pneumoniae,
Staphylococcus Aureus, Meningococci, Group A
Streptococci, Gram Negative Bacilli.

Prone to encapsulated organisms as they have

maturational immune deficiency in production of opsonic
antibodies to the polysaccharide antigens present on
these organisms
3 Months to 3 Years
Consensus Practice Guidelines
 Temperature <39*C , non-toxic - To be observed as

outpatient
 Non-toxic with temperature >39*C - 2 Options

 Obtain blood culture and give empirical antibiotics

 If WBC is >15,000 cells/cmm, obtain blood culture and

start antimicrobial therapy

Rational Choice of Antibiotic in an Office Setting
Site of Likely 1st Line 2nd Line
Infection Organism
Acute Tonsillo Strep Pyogens Pen V, Cephalexin
Pharyngitis (GABHS) Amoxicillin Other
Erythromycin Macrolides
Acute Rhino H. Influenzae Amoxicillin 2nd gen
sinusitis Pneumococci Amox + Clav Cephalosporin
Moraxella C
Acute Otitis GABHS Cefuroxime
Media S Aureus Cefdinir
Rational Choice of Antibiotic in an Office Setting
Site of Likely 1st Line 2nd Line
Infection Organism
Acute H Influenzae Amox + Clav 3rd Generation
Epiglottitis (80-90%) Cephalosporin
GABHS
Pneumococci Ceftriaxone
S Aureus
Mycoplasma
 Rational Choice of Antibiotic in an Office Setting
Site of Infection Likely Organism 1st Line 2nd Line

LRTI: Community H Influenzae Amoxicillin 3rd gen

Acquired Pneumococci Amox + Clav Cephalosporin
Pneumonia Staph Aureus* Cefuroxime
(3 month – 5 yrs) * Severe form –
Hospitalize*
LRTI: Community Pneumococci Penicillin 2nd/3rd gen
Acquired Mycoplasma Amoxicillin Cephalosporin
Pneumonia Amox + Clav *Severe form –
(>5 yrs) Macrolides** Hospitalize*
Cefuroxime
 Rational Choice of Antibiotic in an Office Setting
Site of Likely Organism 1st Line 2nd Line
Infection
Acute Cholera Fluroquinolones Ceftriaxone
Gastroenteritis ETEC Ciprofloxacin Cefixime
EIEC Ofloxacin Azithromycin
Salmonella
Shigella
Campylobacter
Clostridium Difficile
Enteric Fever Salmonella Typhi, OPD: Cefixime, 3rd Generation IV
Paratyphi A Cepodoxime, Cephalosporin
Fluroquinolones*
- Ofloxacin Ceftriaxone
IPD: Ceftriaxone
Rational Choice of Antibiotic in an Office Setting
Site of Likely 1st Line 2nd Line
Infection Organism
UTI E Coli (Uncomplicated) (Complicated)
Proteus Amox + Clav Aminoglycoside
Klebsiella Cephalexin
Fluroquinolones (Resistant)
3rd gen
Cephalosporin
UTI Prophylaxis Cephalexin
Age <2 yrs Cotrimoxazole
Complicated UTI < 5 yrs
VUR Amoxicillin
Renal Scarring Nitrofurantoin
Frequent febrile UTI
Rational Choice of Antibiotic in an Office Setting
Site of Likely 1st Line 2nd Line
Infection Organism
Impetigo and other Strep Pyogens Local- Mupirocin/ 2nd Generation
skin infections Staph Aureus Fusidic Acid Cephalosporins

Oral:
Amox, Clox,
Cephalexin
Surprising that a nation which writes software for
half of the world but cannot write an antibiotic
policy for its own’s country.

- Lancet Infectious Disease

1. History of difficulty feeding
2. History of convulsions
3. Movement only when stimulated
4. Respiratory rate of ≥60/ min
5. Severe chest indrawing
6. Temperature of ≥ 37·5°C
7. Temperature < 35·5°C
Acknowledgements