Managing Pediatric Infections

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

1. What is the child's age and current weight (in kg)?
2. What are the presenting symptoms and their duration?
3. What is the measured temperature and method (rectal, oral, tympanic, axillary)?
4. Does the child have drug allergies (especially penicillin, cephalosporin, sulfa)?
5. What antibiotics has the child taken in the last 30 and 90 days?
6. Is the child immunocompromised or does the child have a chronic condition?
7. What is the child's immunization status (particularly Hib, PCV13, influenza)?
8. 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

"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