Managing Pediatric Infections
Guides systematic evaluation and treatment of common pediatric infections with weight-based antimicrobial dosing, age-stratified empiric regimens, duration of therapy standards, and antibiotic stewardship principles. Covers acute otitis media, pharyngitis, pneumonia, UTI, skin/soft tissue infections, and meningitis.
Why This Skill Exists
Pediatric antimicrobial prescribing errors are among the most common medication errors in children's hospitals and outpatient clinics. Weight-based dosing introduces calculation complexity absent in adult medicine. Antibiotic durations vary by infection site, organism, and age — and inappropriate prescribing drives resistance. This skill ensures each infection is evaluated with the correct diagnostic criteria, treated with the right drug at the right dose for the right duration, and documented with stewardship-compliant reasoning.
Checkpoint A — Intake Verification
Required Intake Questions
- What is the child's age and current weight (in kg)?
- What are the presenting symptoms and their duration?
- What is the measured temperature and method (rectal, oral, tympanic, axillary)?
- Does the child have drug allergies (especially penicillin, cephalosporin, sulfa)?
- What antibiotics has the child taken in the last 30 and 90 days?
- Is the child immunocompromised or does the child have a chronic condition?
- What is the child's immunization status (particularly Hib, PCV13, influenza)?
- Is the child in daycare (risk factor for resistant organisms)?
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
| Scenario |
Age < 6 months |
Age 6 mo - 2 years |
Age ≥ 2 years |
| Severe (moderate-severe otalgia or fever ≥ 39°C) |
Treat |
Treat |
Treat |
| Non-severe, bilateral |
Treat |
Treat |
Treat or observe |
| Non-severe, unilateral |
Treat |
Treat or observe |
Treat or observe |
"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
| Age |
Most Likely Pathogens |
Empiric Outpatient |
Empiric Inpatient |
| 1-3 months |
Chlamydia trachomatis, RSV, S. pneumoniae |
Azithromycin (if afebrile pneumonitis) |
Ampicillin + gentamicin or cefotaxime |
| 3 mo - 5 years |
Viruses (most common), S. pneumoniae |
Amoxicillin 90 mg/kg/day ÷ BID |
Ampicillin 150-200 mg/kg/day ÷ Q6h |
| 5-18 years |
Mycoplasma, S. pneumoniae |
Amoxicillin OR azithromycin |
Ampicillin ± azithromycin |
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
| Age |
Empiric Regimen |
| 0-1 month |
Ampicillin + cefotaxime (or gentamicin) ± acyclovir (if HSV concern) |
| 1-3 months |
Vancomycin + ceftriaxone (or cefotaxime) |
| > 3 months |
Vancomycin + ceftriaxone |
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
| Parameter |
Bacterial |
Viral |
| WBC |
> 1000 (PMN predominant) |
< 500 (lymph predominant) |
| Glucose |
< 40 mg/dL (or < 50% serum) |
Normal |
| Protein |
> 100 mg/dL |
< 100 mg/dL |
| Gram stain |
Often positive |
Negative |
Checkpoint B — Infection Management Review
Quality Audit
| Item |
Requirement |
Pass? |
| Weight verification |
Current weight in kg used for all dose calculations |
|
| Diagnostic criteria |
Infection diagnosis meets guideline-based criteria |
|
| Empiric justification |
Antibiotic choice appropriate for age and suspected pathogen |
|
| Dose accuracy |
mg/kg/day and frequency correct; max dose not exceeded |
|
| Duration documented |
Number of days with explicit stop date |
|
| Allergy cross-check |
Allergy documented and alternative regimen appropriate |
|
| Culture follow-up |
Plan for culture review and narrowing documented |
|
| Stewardship |
No antibiotics for likely viral illness; narrow spectrum preferred |
|
| Return precautions |
Specific red flags communicated to family |
|
| No unexplained [VERIFY] tags |
All flagged items resolved or escalated |
|
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
1---2name: managing-pediatric-infections3description: Guides pediatric infection management with weight-based dosing and duration recommendations. Use when treating pediatric infections, calculating weight-based antibiotics, or managing common childhood infections.4---5
6# Managing Pediatric Infections
7
8Guides systematic evaluation and treatment of common pediatric infections with weight-based antimicrobial dosing, age-stratified empiric regimens, duration of therapy standards, and antibiotic stewardship principles. Covers acute otitis media, pharyngitis, pneumonia, UTI, skin/soft tissue infections, and meningitis.
9
10## Why This Skill Exists
11
12Pediatric antimicrobial prescribing errors are among the most common medication errors in children's hospitals and outpatient clinics. Weight-based dosing introduces calculation complexity absent in adult medicine. Antibiotic durations vary by infection site, organism, and age — and inappropriate prescribing drives resistance. This skill ensures each infection is evaluated with the correct diagnostic criteria, treated with the right drug at the right dose for the right duration, and documented with stewardship-compliant reasoning.
13
14---
15
16## Checkpoint A — Intake Verification
17
18### Required Intake Questions
191. What is the child's age and current weight (in kg)?
202. What are the presenting symptoms and their duration?
213. What is the measured temperature and method (rectal, oral, tympanic, axillary)?
224. Does the child have drug allergies (especially penicillin, cephalosporin, sulfa)?
235. What antibiotics has the child taken in the last 30 and 90 days?
246. Is the child immunocompromised or does the child have a chronic condition?
257. What is the child's immunization status (particularly Hib, PCV13, influenza)?
268. Is the child in daycare (risk factor for resistant organisms)?
27
28### Required Documents
29- Current weight in kilograms (do not estimate from age)
30- Vital signs including temperature
31- Physical examination findings
32- Relevant lab results (CBC, CRP, cultures, urinalysis if applicable)
33- Prior antibiotic history
34- Allergy documentation with reaction type
35
36> All dosing in this skill is weight-based. Verify weight at every encounter — do not carry forward a prior weight.
37
38---
39
40## Step 1 — Acute Otitis Media (AOM)
41
42### Diagnostic Criteria (AAP 2013 AOM Guidelines)
43- Moderate-to-severe bulging of the tympanic membrane, OR
44- New onset otorrhea not from otitis externa, OR
45- Mild bulging of TM with acute (< 48 hours) ear pain or intense TM erythema
46
47### Treatment Decision
48| Scenario | Age < 6 months | Age 6 mo - 2 years | Age ≥ 2 years |
49|----------|---------------|--------------------|----|
50| Severe (moderate-severe otalgia or fever ≥ 39°C) | Treat | Treat | Treat |
51| Non-severe, bilateral | Treat | Treat | Treat or observe |
52| Non-severe, unilateral | Treat | Treat or observe | Treat or observe |
53
54> "Observation" = safety-net antibiotic prescription with 48-72 hour reassessment; must have reliable follow-up.
55
56### First-Line Therapy
57- **Amoxicillin** 80-90 mg/kg/day divided BID × 10 days (< 2 years) or 5-7 days (≥ 2 years with mild disease)
58- Penicillin allergy (non-severe): cefdinir 14 mg/kg/day ÷ daily or BID, or cefuroxime 30 mg/kg/day ÷ BID
59- Treatment failure at 48-72 hours: amoxicillin-clavulanate 90 mg/kg/day (amox component) ÷ BID, or IM ceftriaxone 50 mg/kg × 3 days
60
61---
62
63## Step 2 — Group A Streptococcal Pharyngitis
64
65### Diagnostic Criteria
66- Must confirm with rapid antigen detection test (RADT) or throat culture
67- Do NOT treat based on clinical features alone (Centor/McIsaac scores not validated < 3 years)
68- AAP/IDSA: do not test children < 3 years unless risk factors (sibling with GAS, scarlet fever presentation)
69- Negative RADT in children: back up with throat culture (sensitivity of RADT is 85-95%)
70
71### Treatment
72- **Penicillin V**: 250 mg BID (< 27 kg) or 500 mg BID (≥ 27 kg) × 10 days
73- **Amoxicillin**: 50 mg/kg once daily (max 1000 mg) or 25 mg/kg BID × 10 days
74- 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
75
76### Do Not Treat
77- Asymptomatic carriers (positive culture without symptoms)
78- Viral pharyngitis with conjunctivitis, cough, rhinorrhea, hoarseness (viral features)
79
80---
81
82## Step 3 — Community-Acquired Pneumonia (CAP)
83
84### Age-Based Microbiology Guides Empiric Therapy
85| Age | Most Likely Pathogens | Empiric Outpatient | Empiric Inpatient |
86|-----|----------------------|--------------------|-------------------|
87| 1-3 months | Chlamydia trachomatis, RSV, S. pneumoniae | Azithromycin (if afebrile pneumonitis) | Ampicillin + gentamicin or cefotaxime |
88| 3 mo - 5 years | Viruses (most common), S. pneumoniae | Amoxicillin 90 mg/kg/day ÷ BID | Ampicillin 150-200 mg/kg/day ÷ Q6h |
89| 5-18 years | Mycoplasma, S. pneumoniae | Amoxicillin OR azithromycin | Ampicillin ± azithromycin |
90
91### Duration
92- Uncomplicated CAP: 5-7 days (extending to 10 days for complicated/empyema)
93- Switch from IV to PO when afebrile 24 hours, tolerating PO, improving clinically
94
95### Admission Criteria (PIDS/IDSA 2011)
96- Hypoxia (SpO2 < 90%), significant respiratory distress, dehydration, failed outpatient therapy
97- Age < 3-6 months with suspected bacterial CAP
98- Complicated pneumonia (effusion, empyema, abscess)
99
100---
101
102## Step 4 — Urinary Tract Infection (UTI)
103
104### Diagnostic Requirements (AAP 2016 Febrile UTI in 2-24 Months)
105- Must have BOTH: positive urinalysis (pyuria and/or bacteriuria) AND ≥ 50,000 CFU/mL single organism from catheter or SPA specimen
106- Bag specimens: useful only if negative (high false-positive rate); never use for culture-confirmed diagnosis
107
108### Treatment
109- **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
110- **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
111- Duration: 7-14 days total (7-10 for uncomplicated; 14 for complicated or infant < 2 months)
112
113### Imaging
114- Renal/bladder ultrasound (RBUS): all children 2-24 months with first febrile UTI
115- VCUG: only if RBUS abnormal, recurrent febrile UTI, or atypical organism
116- Do NOT routinely order VCUG after first simple febrile UTI with normal ultrasound (AAP 2016)
117
118---
119
120## Step 5 — Skin and Soft Tissue Infections (SSTI)
121
122### Abscess Management
123- Incision and drainage (I&D) is the primary treatment for abscesses
124- Antibiotics added to I&D for: surrounding cellulitis, systemic symptoms, immunocompromised, failed I&D, extremes of age
125
126### MRSA Considerations
127- Empiric MRSA coverage for purulent SSTI (abscess, furuncle with surrounding cellulitis)
128- **TMP-SMX**: 8-12 mg/kg/day (TMP component) ÷ BID
129- **Clindamycin**: 30-40 mg/kg/day ÷ TID (check local D-test resistance rates)
130- **Doxycycline**: 2-4 mg/kg/day ÷ BID (age ≥ 8 years; AAP now permits shorter courses in younger children)
131
132### Non-Purulent Cellulitis
133- Beta-hemolytic strep more likely; empiric with cephalexin 50-100 mg/kg/day ÷ QID or dicloxacillin
134- Add MRSA coverage if not responding at 48 hours
135
136---
137
138## Step 6 — Bacterial Meningitis (Emergency)
139
140### Empiric Therapy by Age
141| Age | Empiric Regimen |
142|-----|----------------|
143| 0-1 month | Ampicillin + cefotaxime (or gentamicin) ± acyclovir (if HSV concern) |
144| 1-3 months | Vancomycin + ceftriaxone (or cefotaxime) |
145| > 3 months | Vancomycin + ceftriaxone |
146
147### Critical Steps
148- Obtain blood culture and LP (CSF) BEFORE antibiotics unless LP will delay antibiotics > 30 minutes
149- Dexamethasone 0.15 mg/kg IV Q6h × 2 days — give BEFORE or WITH first antibiotic dose (benefit proven for H. influenzae; consider for pneumococcal)
150- Duration: S. pneumoniae 10-14 days; N. meningitidis 5-7 days; GBS 14-21 days; Listeria 21+ days; gram-negative 21 days
151
152### CSF Interpretation
153| Parameter | Bacterial | Viral |
154|-----------|-----------|-------|
155| WBC | > 1000 (PMN predominant) | < 500 (lymph predominant) |
156| Glucose | < 40 mg/dL (or < 50% serum) | Normal |
157| Protein | > 100 mg/dL | < 100 mg/dL |
158| Gram stain | Often positive | Negative |
159
160---
161
162## Checkpoint B — Infection Management Review
163
164- [ ] Diagnosis meets established clinical and/or microbiologic criteria
165- [ ] Weight verified in kilograms on day of prescribing
166- [ ] Allergy status confirmed with reaction type
167- [ ] Antibiotic choice matches site, age, and local resistance patterns
168- [ ] Dose calculated per kg with total dose and frequency confirmed
169- [ ] Duration specified with stop date documented
170- [ ] Culture results (pending or final) documented
171- [ ] Red flags for deterioration communicated to family
172- [ ] Follow-up plan established (48-72 hour reassessment for observation pathway)
173- [ ] All [VERIFY] flags resolved or escalated
174
175---
176
177## Quality Audit
178
179| Item | Requirement | Pass? |
180|------|-------------|-------|
181| Weight verification | Current weight in kg used for all dose calculations | |
182| Diagnostic criteria | Infection diagnosis meets guideline-based criteria | |
183| Empiric justification | Antibiotic choice appropriate for age and suspected pathogen | |
184| Dose accuracy | mg/kg/day and frequency correct; max dose not exceeded | |
185| Duration documented | Number of days with explicit stop date | |
186| Allergy cross-check | Allergy documented and alternative regimen appropriate | |
187| Culture follow-up | Plan for culture review and narrowing documented | |
188| Stewardship | No antibiotics for likely viral illness; narrow spectrum preferred | |
189| Return precautions | Specific red flags communicated to family | |
190| No unexplained [VERIFY] tags | All flagged items resolved or escalated | |
191
192---
193
194## Guidelines
195
196- Follow AAP 2013 AOM guidelines for acute otitis media diagnosis and treatment
197- Follow IDSA 2012 and AAP guidelines for GAS pharyngitis
198- Follow PIDS/IDSA 2011 guidelines for community-acquired pneumonia in children
199- Follow AAP 2016 guidelines for UTI in febrile infants 2-24 months
200- Follow IDSA 2014 SSTI guidelines adapted for pediatrics
201- Follow IDSA 2004 meningitis guidelines with AAP updates
202- Weight-based dosing: always calculate per kilogram, never estimate from age
203- Maximum adult doses: always cap pediatric doses at adult maximum (e.g., amoxicillin max 3g/day)
204- Penicillin allergy: true IgE-mediated allergy has < 2% cross-reactivity with cephalosporins — document reaction type
205- Antibiotic stewardship: shortest effective course, narrowest effective spectrum, culture-directed when possible
206- This skill produces clinical documentation; it does not replace clinical judgment
CaseMark