Managing Pediatric Infections

Required Documents

• Current weight in kilograms (do not estimate from age)
• Vital signs including temperature
• Physical examination findings
• Relevant lab results (CBC, CRP, cultures, urinalysis if applicable)
• Prior antibiotic history
• Allergy documentation with reaction type

All dosing in this skill is weight-based. Verify weight at every encounter — do not carry forward a prior weight.

Step 1 — Acute Otitis Media (AOM)

Diagnostic Criteria (AAP 2013 AOM Guidelines)

• Moderate-to-severe bulging of the tympanic membrane, OR
• New onset otorrhea not from otitis externa, OR
• Mild bulging of TM with acute (< 48 hours) ear pain or intense TM erythema

Treatment Decision

"Observation" = safety-net antibiotic prescription with 48-72 hour reassessment; must have reliable follow-up.

First-Line Therapy

• Amoxicillin 80-90 mg/kg/day divided BID × 10 days (< 2 years) or 5-7 days (≥ 2 years with mild disease)
• Penicillin allergy (non-severe): cefdinir 14 mg/kg/day ÷ daily or BID, or cefuroxime 30 mg/kg/day ÷ BID
• Treatment failure at 48-72 hours: amoxicillin-clavulanate 90 mg/kg/day (amox component) ÷ BID, or IM ceftriaxone 50 mg/kg × 3 days

Step 2 — Group A Streptococcal Pharyngitis

Diagnostic Criteria

• Must confirm with rapid antigen detection test (RADT) or throat culture
• Do NOT treat based on clinical features alone (Centor/McIsaac scores not validated < 3 years)
• AAP/IDSA: do not test children < 3 years unless risk factors (sibling with GAS, scarlet fever presentation)
• Negative RADT in children: back up with throat culture (sensitivity of RADT is 85-95%)

Treatment

• Penicillin V: 250 mg BID (< 27 kg) or 500 mg BID (≥ 27 kg) × 10 days
• Amoxicillin: 50 mg/kg once daily (max 1000 mg) or 25 mg/kg BID × 10 days
• Penicillin allergy: cephalexin 20 mg/kg/dose BID (max 500 mg/dose) × 10 days; if cephalosporin allergy too: azithromycin 12 mg/kg day 1 (max 500 mg), then 6 mg/kg/day days 2-5

Do Not Treat

• Asymptomatic carriers (positive culture without symptoms)
• Viral pharyngitis with conjunctivitis, cough, rhinorrhea, hoarseness (viral features)

Step 3 — Community-Acquired Pneumonia (CAP)

Age-Based Microbiology Guides Empiric Therapy

Duration

• Uncomplicated CAP: 5-7 days (extending to 10 days for complicated/empyema)
• Switch from IV to PO when afebrile 24 hours, tolerating PO, improving clinically

Admission Criteria (PIDS/IDSA 2011)

• Hypoxia (SpO2 < 90%), significant respiratory distress, dehydration, failed outpatient therapy
• Age < 3-6 months with suspected bacterial CAP
• Complicated pneumonia (effusion, empyema, abscess)

Step 4 — Urinary Tract Infection (UTI)

Diagnostic Requirements (AAP 2016 Febrile UTI in 2-24 Months)

• Must have BOTH: positive urinalysis (pyuria and/or bacteriuria) AND ≥ 50,000 CFU/mL single organism from catheter or SPA specimen
• Bag specimens: useful only if negative (high false-positive rate); never use for culture-confirmed diagnosis

Treatment

• Outpatient (well-appearing, tolerating PO): cephalexin 50-100 mg/kg/day ÷ TID-QID, or cefixime 8 mg/kg/day ÷ daily, or TMP-SMX 8-12 mg/kg/day (TMP) ÷ BID
• Inpatient (toxic-appearing, < 2 months, or unable to tolerate PO): ceftriaxone 50-75 mg/kg/day IV or gentamicin 5-7.5 mg/kg/day IV
• Duration: 7-14 days total (7-10 for uncomplicated; 14 for complicated or infant < 2 months)

Imaging

• Renal/bladder ultrasound (RBUS): all children 2-24 months with first febrile UTI
• VCUG: only if RBUS abnormal, recurrent febrile UTI, or atypical organism
• Do NOT routinely order VCUG after first simple febrile UTI with normal ultrasound (AAP 2016)

Step 5 — Skin and Soft Tissue Infections (SSTI)

Abscess Management

• Incision and drainage (I&D) is the primary treatment for abscesses
• Antibiotics added to I&D for: surrounding cellulitis, systemic symptoms, immunocompromised, failed I&D, extremes of age

MRSA Considerations

• Empiric MRSA coverage for purulent SSTI (abscess, furuncle with surrounding cellulitis)
• TMP-SMX: 8-12 mg/kg/day (TMP component) ÷ BID
• Clindamycin: 30-40 mg/kg/day ÷ TID (check local D-test resistance rates)
• Doxycycline: 2-4 mg/kg/day ÷ BID (age ≥ 8 years; AAP now permits shorter courses in younger children)

Non-Purulent Cellulitis

• Beta-hemolytic strep more likely; empiric with cephalexin 50-100 mg/kg/day ÷ QID or dicloxacillin
• Add MRSA coverage if not responding at 48 hours

Step 6 — Bacterial Meningitis (Emergency)

Empiric Therapy by Age

Critical Steps

• Obtain blood culture and LP (CSF) BEFORE antibiotics unless LP will delay antibiotics > 30 minutes
• Dexamethasone 0.15 mg/kg IV Q6h × 2 days — give BEFORE or WITH first antibiotic dose (benefit proven for H. influenzae; consider for pneumococcal)
• Duration: S. pneumoniae 10-14 days; N. meningitidis 5-7 days; GBS 14-21 days; Listeria 21+ days; gram-negative 21 days

CSF Interpretation

Checkpoint B — Infection Management Review

• Diagnosis meets established clinical and/or microbiologic criteria
• Weight verified in kilograms on day of prescribing
• Allergy status confirmed with reaction type
• Antibiotic choice matches site, age, and local resistance patterns
• Dose calculated per kg with total dose and frequency confirmed
• Duration specified with stop date documented
• Culture results (pending or final) documented
• Red flags for deterioration communicated to family
• Follow-up plan established (48-72 hour reassessment for observation pathway)
• All [VERIFY] flags resolved or escalated

Quality Audit

Guidelines

• Follow AAP 2013 AOM guidelines for acute otitis media diagnosis and treatment
• Follow IDSA 2012 and AAP guidelines for GAS pharyngitis
• Follow PIDS/IDSA 2011 guidelines for community-acquired pneumonia in children
• Follow AAP 2016 guidelines for UTI in febrile infants 2-24 months
• Follow IDSA 2014 SSTI guidelines adapted for pediatrics
• Follow IDSA 2004 meningitis guidelines with AAP updates
• Weight-based dosing: always calculate per kilogram, never estimate from age
• Maximum adult doses: always cap pediatric doses at adult maximum (e.g., amoxicillin max 3g/day)
• Penicillin allergy: true IgE-mediated allergy has < 2% cross-reactivity with cephalosporins — document reaction type
• Antibiotic stewardship: shortest effective course, narrowest effective spectrum, culture-directed when possible
• This skill produces clinical documentation; it does not replace clinical judgment