3.08 - Respiratory Tract Infections [updated]

Algorithm for the Diagnosis community acquired pneumonia (CAP):

1) Is there pneumonia?

     Patients need to fulfill at least TWO of A and ONE of B 

            A. Clinical criteria:

      • Acute onset of fever (T ≥ 38oC).
      • Recent onset of cough or worsening of cough (< 2 weeks duration).
      • New onset of increased sputum production or a change in the character of the sputum (yellowish or greenish).
      • Recent onset of progressively increased dyspnoea.
      • Acute onset of pleuritic chest pain.
      • Auscultatory findings suggestive of pneumonia on physical examination which include bronchial breath sounds, increased vocal resonance, crepitations.
      • Raised total white cell counts (> 11 x 109 /L).
      • For those with pleural effusion, pleurocentesis confirm the presence of neutrophilic inflammatory exudate.
            AND

            B. Imaging criteria:
      • Radiographic image (CXR or CT thorax) shows evidence of lung field infiltrates.
      • For patients who have a normal CXR at presentation but have signs and symptoms suggestive of pneumonia, a diagnosis of pneumonia could still be confirmed in retrospect if a repeat chest imaging demonstrates evidence of pneumonia within 48 hours after admission.
           
2) Essential Investigations
  • Chest X-ray
  • Sputum for culture
  • Blood culture (in case of moderate to severe CAP)
3) Assess Severity
  • Stratify patient according to CURB 65 Score:
Confusion
Urea > 7 mmol/L 
Respiratory Rate ≥ 30 / min
Blood Pressure - SBP < 90 mmHg; DBP ≤ 60 mmgHg
Age > 65 years old

  • Score 0-1: Home antibiotics unless patient has other co-morbidity or difficult social circumstances.
  • Score 2: Admit to hospital.
  • Score 3: Admit to hospital and consider ICU referral.

A) Adults

Disease / Etiology

Preferred

Alternative

Comments

Community Acquired Pneumonia

S. pneumoniae, Klebsiella pneumonia, H. influenzae, Moraxella catarrhalis, Legionella sp., Mycoplasma pneumoniae, Chlamydophila (pneumoniae & psittaci), respiratory viruses.

Staph aureus can also cause CAP, but is uncommon.

Total duration of beta lactam antibiotics: 5-7 days

Azithromycin: 3 days

If suspected Legionella is suspected,

Azithromycin 5 days or Doxycycline 7-10 days (up to 21 days)

Switch to oral therapy when clinical condition improves and patient is able to take orally


Low Severity:
CURB 65 = 0 – 1
or
CRB 65 score = 0



If hospitalized due to other reason





 
Amoxicillin 500mg-1000mg PO q8H 

OR


Co-amoxiclav 625 mg PO q8H
±
Doxycycline 200 mg PO stat, then 100 mg PO q12H
for 5-7 days
Or
Azithromycin 500mg PO q24H for 3 days


Same as above but consider IV

 

Cefuroxime 500 mg PO q12H
±
Doxycycline 200 mg PO stat, then 100 mg PO q12H
for 5-7 days

Or
Azithromycin 500mg PO q24H for 3 days


If Legionella suspected,

Azithro: 5 days

Or

Doxycycline : 7-10 days, (up to 21 days)

 

Moderate risk penicillin allergy (delayed rash which is not urticarial or DRESS / SJS / TEN):

 

Replace Co-Amoxiclav with: Cefuroxime 500mg orally BD OR if unable to tolerate oral therapy: Ceftriaxone ± Metronidazole

 

High risk Penicillin / Cephalosporin allergy: History suggestive of high risk (e.g. anaphylaxis, urticaria, angioedema, bronchospasm, DRESS / SJS / TEN): Consult ID/Chest



Inpatient (CURB > 2)
Moderate severity:
CURB 65 = 2, (9% mortality 
or
CRB 65 = 1 - 2

Co-amoxiclav 1.2 gm IV q8H


OR  


Cefuroxime 1.5 gm IV q8H

For 5-7 days

±

Azithromycin 500 mg PO/IV q24H
for 3 days
OR
Doxycycline 100 mg PO q12H
for 5-7 days


Ceftriaxone 2 gm IV q24H for 5-7 days
±


Azithromycin 500 mg PO/IV q24H
for 3 days

 

OR


Doxycycline 100 mg PO q12H for 5-7 days

Hospitalisation is recommended.

 

Moderate risk penicillin allergy (delayed rash which is not urticarial or DRESS / SJS / TEN):

 

Replace Co-Amoxiclav with: Cefuroxime 500mg orally BD OR if unable to tolerate oral therapy: Ceftriaxone ± Metronidazole

 

High risk Penicillin / Cephalosporin allergy: History suggestive of high risk (e.g. anaphylaxis, urticaria, angioedema, bronchospasm, DRESS / SJS / TEN): Consult ID/Chest

If MRSA suspected:
Add Vancomycin 15 - 20 mg/kg q8 - 12H

If Melioidosis suspected:
Use Carbapenem or Ceftazidime


High Severity:
CURB 65 = 3 – 5, 15 – 40% mortality)
or
CRB = 3 - 4

 

Piperacillin / Tazobactam 4.5 gm IV q6H

Azithromycin 500 mg IV q24H

For 5-7 days

Cefepime 2 gm IV q8H

Azithromycin 500 mg IV q24H


For 5-7 days
Note: 
Consider Meropenem if Melioidosis is suspected.



Moderate risk penicillin allergy ( delayed rash which is not urticarial or DRESS / SJS / TEN):

Replace Piperacillin / Tazobactam with: Cefepime 2g IV 8-hourly ± Metronidazole 500mg IV q12H (if suspected aspiration or recent thoraco-abdominal surgery).

 

High risk penicillin / cephalosporin allergy (History suggestive of high risk (e.g. anaphylaxis, urticaria, angioedema, bronchospasm, DRESS / SJS / TEN): Refer ID/Chest

 

Patients should be managed in HDU or ICU.

For those with septicaemia, consider aminoglycoside.
 

If MRSA suspected-

Add Vancomycin 15 - 20 mg/kg q8 – 12H


Risk factors for Melioidosis:
Uncontrolled diabetes and exposure history.


Hospital Acquired Pneumonia and Ventilator- associated Pneumonia

HAP: Pneumonia occurring ≥ 48 hours after hospital admission that was NOT incubating at the time of the hospital admission

VAP: Pneumonia occurring ≥ 48 hours after endotracheal intubation

 

Pseudomonas aeruginosaAcinetobacter baumannii, various gram negative organisms and MRSA.

Many of these are multi-drug-resistant organisms.

Atypical organisms, e.g. Mycoplasma spChlamydophila sp or Legionella are rare. 

 

LOW RISK MDR pathogens 

Hospitalised in a low risk (general ward) for any duration, OR

Hospitalised in ICU / HDU ≤ 5 days

 

HIGH RISK MDR pathogens:

Risk factors for mortality – need for ventilatory support, septic shock

Prior intravenous antibiotic within past 90 days

Recent prolonged hospital stay (>5 days of hospitalisation)

Previous colonisation with MDR pathogens

Increased risk of Gram negative bacteria – structural lung disease (bronchiectasis)

MRSA risk factor

- patients located in units were more than 10%-20% of S aureus isolates are MRSA

- Patients in units where the prevalence of MRSA is unknown

 Risk of MDR is lower with early onset HAP/VAP

 

CRITERIA FOR SEVERE HAP 

• Systolic BP ≤ 90 mmHg

• Multi-lobar chest X-ray involvement

• Respiratory rate:

    Age ≤ 50 years: ≥ 25 breaths / min

    Age > 50 years: ≥ 20 breaths / min

• Tachycardia (Heart rate ≥ 125 bpm)

• Confusion (new onset)

• Acute hypoxia:

     Age ≤ 50 years: PaO2 < 70mmHg or SpO2 ≤ 93%

     Age > 50 years: PaO2 < 60mmHg or SpO2 ≤ 90%

• pH (arterial) < 7.35

• Lactate ≥ 2mmol/L

 PRIOR TO ANTIBIOTICS, specimens/cultures should be sent for identification of causative organism

Early onset HAP/VAP

(2-4 days of admission/intubation)


Co-amoxiclav 1.2 gm IV q8H for 5-7 days

Azithromycin 500 mg PO q24H
for 3 days

Ceftriaxone 2 gm IV q24H for 5-7 days

Azithromycin 500 mg PO q24H
for 3 days

±

Metronidazole 400mg PO q8-12H

Or

Metronidazole 500mg IV q8H

(if suspected aspiration or recent thoraco-abdominal surgery)

Moderate risk penicillin allergy (delayed rash which is not urticarial or DRESS / SJS / TEN):

 

Replace Co-amoxiclav with Cefuroxime 500mg orally BD OR if unable to tolerate oral therapy: Ceftriaxone ± Metronidazole

 

High risk Penicillin / Cephalosporin allergy: History suggestive of high risk (e.g. anaphylaxis, urticaria, angioedema, bronchospasm, DRESS / SJS / TEN): Consult ID/Chest

Late onset HAP/VAP

(5 days or more of admission/intubation)

 

Or

 

Severe HAP
 

Piperacillin / Tazobactam 4.5 gm IV q6H for 7 days

 

Or

 

Cefepime 2gm IV q8H for 7 days

 



Meropenem 1 gm q8H for 7 days
 

Moderate risk penicillin allergy ( delayed rash which is not urticarial or DRESS / SJS / TEN):

Replace Piperacillin / Tazobactam with: Cefepime 2g IV 8-hourly ± Metronidazole 500mg IV q12H (if suspected aspiration or recent thoraco-abdominal surgery).

 

High risk penicillin / cephalosporin allergy (History suggestive of high risk (e.g. anaphylaxis, urticaria, angioedema, bronchospasm, DRESS / SJS / TEN): Refer ID/Chest

If patient suspected to be colonized with MRSA, add vancomycin 20 mg/kg IV single dose then 15 mg/kg IV q12H.

If patient is colonized with extreme drug resistant Acinetobacter baumaunii, start Polymyxin B 2.5 mg/kg IV STAT over 2 hours then maintenance dose to start 12 hours after loading dose, 1.5 mg/kg IV q12H over 1 hour. (Consider using adjusted body weight for obese patient)

Duration of antibiotics could be shortened to 7 days even for MDR Pseudomonas aeruginosa and Acinetobacter baumanii infection.

Longer duration may be indicated depending on clinical, radiological and laboratory parameters.

 

To de-escalate antibiotics according to culture and sensitivity results.

Aspiration Pneumonia

Most aspiration is sterile & requires physiotherapy, not antibiotics.

If infection develops, anaerobes & mouth streptococci (e.g. Milleri/anginosus) should be treated.

Antibiotics are not indicated for aspiration (chemical) pneumonitis

 
Community Acquired
 

Co-amoxiclav 625 mg PO q8H
  
OR

Co-amoxiclav 1.2 gm IV q8H

for 5-7 days

 

Cefuroxime 750 mg IV q8H
+
Metronidazole 500 mg IV q8H

 

for 5-7 days

Minor degree of aspiration does not require antibiotics.

With acute intestinal obstruction:
Add Metronidazole 500 mg IV q8H.

 
Hospital Acquired


 
Piperacillin / Tazobactam 4.5 gm IV q6H

   

Other Lower Respiratory Tract Infections

Lung Abscess

  • Those with cavities < 2 cm is also known as necrotising pneumonia or lung gangrene.
  • It is often secondary to aspiration - hence, anaerobes are important. 
  • Other causes include Gram positive cocci, Klebsiella pneumonia, S. milleri / anginosus and rarely, Norcardia sp..                                                                                                                                                
  • May change to oral regime once clinical improvement seen

Empirical

Community acquired:
Co-amoxiclav 1.2 gm IV q8H

Once improved, change to PO coamoxiclav 1g TDS
 
Ceftriaxone 2g IV q24H
+
 *Metronidazole 500 mg IV q8H

OR

Clindamycin
600mg IV/PO q6H

Duration of treatment:

Drained abscess:

may require 2 – 4 weeks of antibiotics

Undrained abscess/empyema: may require 4 – 6 weeks of antibiotics

 

Lung empyema: Attempts should be made to drain the collection

 

*Metronidazole in cases of lung abscess when aspiration is suspected

 

Meropenem 1 gm IV q8H if Melioidosis is suspected

 

Risk factors for Melioidosis:

DM with poor glycemic control

Renal Dysfunction

Chronic Lung Disease

Occupational or Recreational Exposure

If penetrating injury, consider adding Vancomycin for MRSA cover.


Staphylococcus aureus
 
Cloxacillin 2g q4-6H
 
Cefazolin 2g IV q8H
 
Duration: 4 – 6 weeks, depending on clinical response. In rare cases (slow response to antibiotics) may need prolonged therapy

 

May change to oral therapy  (cephalexin, cloxacillin) to complete the duration once patient improved

Bronchiectasis

Offer annual influenza immunisation and polysaccharide pneumococcal to all patients with bronchiectasis. (D)

Acute Exacerbation of Bronchiectasis

Pseudomonas aeruginosa, Haemophilus influenza, Streptococcus pneumoniae, Moraxella, Catarrhalis, Staph aureus.

Bronchiectasis severity index:

 

Mild/ Moderate:

  •  Exacerbation can be controlled with oral antibiotic treatment

Severe:

  •  Exacerbation requires intravenous antibiotic treatment or hospitalization.  Those that present with at least one of the following conditions are also considered severe
  •  Exacerbated acute or chronic respiratory failure,
  • Significant deterioration in oxygen saturation,
  • High temperature or other criteria for sepsis,
  •  Frank hemoptysis or significant deterioration in lung function.

Very severe

  • Exacerbations that present with hemodynamic instability, altered level of consciousness or need for admission to an intensive or intermediate care unit

 

Reference: Martínez-García MÁ et al. Spanish Guidelines on Treatment of Bronchiectasis in Adults. Arch Bronconeumol. 2018 Feb;54(2):88-98. doi: 10.1016/j.arbres.2017.07.016. Epub 2017 Nov 9.


 

Mild – moderate


 
Co-amoxiclav 625 mg PO q8H

 
Cefuroxime 500 mg PO q12H


Moderate risk penicillin allergy ( delayed rash which is not urticarial or DRESS / SJS / TEN):

Replace Co-amoxiclav with Cefuroxime 500mg orally

 

High risk penicillin / cephalosporin allergy (History suggestive of high risk (e.g. anaphylaxis, urticaria, angioedema, bronchospasm, DRESS / SJS / TEN): Refer ID/Chest

 
Severe
or
Failed Oral Therapy

 
Ceftazidime 2 gm IV q8H
  
±

Gentamicin 3 - 5 mg/kg IV q24H
OR
Amikacin 15 mg/kg IV q24H
(if resistant organism is suspected)

 
Tazocin 4.5g QID
OR

Cefepime 2 gm IV q8H

Moderate risk penicillin allergy ( delayed rash which is not urticarial or DRESS / SJS / TEN):

Replace Piperacillin/Tazobactam with: Cefepime 2gm IV q8H

                                            

High risk penicillin / cephalosporin allergy (History suggestive of high risk (e.g. anaphylaxis, urticaria, angioedema, bronchospasm, DRESS / SJS / TEN): Refer ID/Chest

Bronchiectasis (chronic suppressive treatment)

Antibiotic treatment may only be justified for patients with frequent exacerbations (≥ 3 per last 12 months; or ≥ 2 per last 12 months with significant comorbidities), antibiotic treatment may be justified

Culture must be taken prior to Cyclical antibiotic



Regular maintenance treatment


Azithromycin 500 mg PO
3 times/week

 
Erythromycin Ethyl Succinate (EES) 400 mg PO q12H

 

Cyclical antibiotic


Ceftazidime 2 gm IV q8H

±
  
Gentamicin 3 - 5 mg/kg IV q24H
OR
Amikacin 15 mg/kg IV q24H

 
Cefepime 2 gm IV q8H

OR

Ciprofloxacin 750 mg PO q12H 
 
Duration: every 12 weeks.

Bronchiectasis Eradication Treatment


Pseudomonas 

First line treatment: Ciprofloxacin 500–750mg PO q12H for 2 weeks

Followed by a 3 month course of nebulised:

Colistin 2MU q12H

Or

Gentamicin 160mg q12H

or

Amikacin 250mg-500mg q12H


Second line treatment:

iv Ceftazidime* ±

Gentamicin 3 - 5 mg/kg IV q24H 
OR
Amikacin 15 mg/kg IV q24H

 

For 2 weeks,

 

Followed by a 3 month course of nebulised:

Colistin 2MU q12H

Or

Gentamicin 160mg q12H

Or

Amikacin 250mg-500mg q12H

 *To treat based on sensitivities

Acute Exacerbation of COPD 

Anthonisen guideline on severity:

Type1: fulfilled all 3 criterias of below (antibiotics indicated)

Increased purulence in sputum

Increased sputum volume

Increased dyspnoea

Type 2:

2 of above

(Consider antibiotics) 

Or

Patient Intubated (GOLD 2019)

 
Outpatient 

 

Co-amoxiclav 625 mg PO q8H for 5 – 7 days


±
Doxycycline 200 mg PO stat, then 100 mg PO q12H
5-7 days

 

Or


Azithromycin 500mg q24H for 3 days 

 

Cefuroxime 500 mg PO q12H for 5 -7 days


±
Doxycycline 200 mg PO stat, then 100 mg PO q12H for 5 – 7 days

 

Or

 

Azithromycin 500mg q24H for 3 days 



Not all COPD exacerbations require antibiotic therapy.

Antibiotic may be considered if the patient has one or more of the following symptoms or scenario:
· Purulent sputum production
· Fever
· Exacerbation which requires hospitalisation

 
Inpatient 

 

Co-amoxiclav 1.2gm IV q8H
OR  
Cefuroxime 1.5gm IV q8H

For 5-7 days

+/-

Azithromycin 500mg IV q24H for 3 days


OR


Doxycycline 100mg PO q12H for 5-7 days



Ceftriaxone 2 gm IV q24H

5-7 days


+/-


Azithromycin 500 mg IV q24H for 3 days

 

OR


Doxycycline 100 mg PO q12H for 5-7 days

Viral infections

 

Influenza- treat ‘at risk’ populatio

Oseltamivir 75mg PO q12H for 5 days. Initiate within 48 hours of influenza symptom onset

 

Treat at risk population if suspected influenza:

-Chronic respiratory disease (including COPD and asthma)

-Significant cardiovascular disease (not hypertension)

-Severe immunosuppression

-Chronic neurological, renal or liver disease

-Diabetes mellitus

-Morbid obesity (BMI>40)

-Persons of any age who are hospitalised with influenza, regardless of illness duration prior to hospitalisation

-Children younger than 6 months and adults ≥65 years

-Pregnant women and those within 2 weeks postpartum


Influenza

Post-exposure prophylaxis

Oseltamivir 75mg PO q24H for 10 days.

 

 

Varicella zoster pneumonia

Acyclovir 10mg/kg IV q8H for 7 days

 

Or

 

Valaciclovir 1000mg PO q8H x 5 days

(Not in formulary)

 

 

Pregnancy (3rd trimester): Acyclovir 800mg PO 5x/day or 10mg/kg IV q8H x 5 days

Switching from IV to Oral therapy

  • Usually on Day 3.
  • When temperature < 37.5oC.
  • Clinically improving and/or inflammatory markers showing downward trend.
  • No contraindications to take orally.

    Options:

    • Co-amoxiclav 625 mg TDS* ± Azithromycin / Doxycycline
    • Cefuroxime 750 mg BD ± Azithromycin / Doxycycline
    • Moxifloxacin (only if the above contraindicated)

    Note: Choose based on C&S if available.

 

Duration of Treatment

  • 5 - 7 days for most.
  • May extend treatment to 10 days in Pseudomonas aeruginosa and Legionella infections.

*Coamoxiclav 1g TDS for abscesses/empyema

* Asthma exacerbation

Clinical practice guidelines recommend against empiric antibiotic therapy for the treatment of an asthma exacerbation, because most respiratory infections that trigger an exacerbation of asthma are viral rather than bacterial  




B) Paediatrics

Disease / Etiology

Preferred

Alternative

Comments

Community Acquired Bacterial Pneumonia, Pleural Effusion and Empyema

 
1 - 3 months
Streptococcal pneumoniae
Haemophilus influenza
Staphylococcus aureus 

 

Ampicillin 50mg/kg/dose IV q6H


AND /OR

 

Cloxacillin 50mg/kg/dose IV q6H


 

Co-amoxiclav 25-30mg/kg/dose (Amoxicillin component) IV q8H


OR


Cefuroxime 25mg/kg/dose IV q8H

 

Use Cloxacillin if one suspects Staphylococcus aureus (MSSA) pneumoniae / sepsis in critically ill infants, children < 1 year of age or in the presence of pneumatocoeles.

For patients with significant beta-lactam allergy, macrolides are alternatives.

Add IV Metronidazole or change Amoxicillin to Co-amoxiclav if aspiration of anaerobes is a possibility.

 

Use Co-amoxiclav 30mg/kg/dose for pneumonia with acute otitis media 
 
Chlamydia trachomatis
Bordetella pertussis
 

Erythromycin 15mg/kg/dose PO q6H OR 

Azithromycin (preferred choice for infant < 1 month old): 

< 6 months old: 10mg/kg/dose PO q24H for 5 days                                               

 ≥ 6 months old: 10 mg/kg/dose PO q24H on Day 1 then 5 mg/kg/dose PO q24H on Day 2 – 5



3 months to 5 years
Streptococcal pneumoniae
Haemophilus influenzae
Staphylococcus aureus





















Mycoplasma pneumoniae
 

Outpatient:

Amoxycillin 25-30mg/kg/dose PO q8H

 

Inpatient:

Ampicillin 50 mg/kg/dose IV q6H





Erythromycin ethylsuccinate 20mg/kg/dose PO q12H







Co-amoxiclav 25mg/kg/dose (Amoxicillin component) PO q12H

Cefuroxime 15mg/kg/dose PO q12H

 




Co-amoxiclav 25-30mg/kg/dose (Amoxicillin component) IV q8H
OR

Cefuroxime 25-30mg/kg/dose IV q8H







Azithromycin 10 mg/kg/dose PO q24H on Day 1 then 5 mg/kg/dose PO q24H on Day 2 – 5

 > 5 years
Streptococcal pneumoniae



Mycoplasma pneumonia

 





Moraxella catarrhalis


 

Outpatient:

Amoxycillin 15mg/kg/dose PO q8H


Inpatient:

Ampicillin 50 mg/kg/dose IV q6H

 

 

 

 

Erythromycin ethylsuccinate 20mg/kg/dose PO q12H


Co-amoxiclav 25mg/kg/dose (Amoxicillin component) PO q12H


 

Co-amoxiclav 25mg/kg/dose (Amoxicillin component) PO q12H

 


Co-amoxiclav 25-30mg/kg/dose (Amoxicillin component) IV q8H
OR
Cefuroxime 25-30mg/kg/dose IV q8H

Non Cystic Fibrosis Bronchiectasis

 
Patient with no previous bacteriology result.

 
Co-amoxiclav 25-30mg/kg/dose (Amoxicillin component) IV q8H

 
Cefuroxime 25-30mg/kg/dose IV q8H
OR
Ceftriaxone 50 mg/kg/dose IV q24H
 
Follow the most recent sputum bacteriology result in deciding which antibiotics to use.

The total duration of antibiotics should be for 14 days.

Azithromycin 5 mg/kg/dose (M, W, F) is considered especially when there are frequent exacerbations and decline in lung function.






 
In patients chronically colonized with Pseudomonas aeruginosa (2 consecutive positive cultures or 3 positive cultures in 1 year)
 

Addition of nebulized Amikacin for 1 to 3 months should be considered:

Age

Dose

< 1 year

62.5 mg q12H

1 - 5 years

125 mg q12H

6 - 12 years

250 mg q12H

> 12 years

500 mg q12H

Cystic Fibrosis Antibiotic Prophylaxis

 
Oral Antibiotic Prophylaxis


Cloxacillin:
< 10 kg: 125 mg q12H
10 - 15 kg: 250 mg q12H
> 15 kg: 25 mg/kg q12H

Azithromycin (immunomodulator):
< 15 kg: 10 mg/kg q24H (M,W,F)
15 - 40 kg: 250 mg q24H (M,W,F)
> 40 kg: 500 mg q24H (M,W,F)

   
The aim of prophylactic Cloxacillin is to reduce Staphylococcus aureus infection and subsequent inflammation during the time of lung development when the lung is most vulnerable. It is used in ALL children below 5 years old or in children > 5 years when there are more than 2 isolates of Staphylococcus aureus in a year.
 
Nebulized antibiotic as prophylactic treatment
Pseudomonas aeruginosa
Burkholdelia cepacia complex



























Pseudomonas aeruginosa only

 

Nebulized Amikacin:

Age

Dose

< 1 year

62.5 mg q12H

1 - 5 years

125 mg q12H

6 - 12 years

250 mg q12H

> 12 years

500 mg q12H

 

OR

 

 


Nebulized Colomycin (Colistin):

Age

Dose

< 2 year

500,000 units q12H

2 - 8 years

1,000,000 units q12H

> 8 years

2,000,000 units q12H

1,000,000 units = 1 Mega units



Nebulized Gentamicin:

Age

Dose

< 2 years

20 mg q12H

2 - 8 years

40 mg q12H

> 8 years

80 mg q12H

   
To be used for 3 months


Bronchospasm can be reduced by:
i)  Diluting with water
ii) Pre-dose with bronchodilator.

First dose in hospital 


Infective Pulmonary Cystic Fibrosis Exacerbation


Staphylococcus aureus

Outpatient:                                          

If patient is on cloxacillin prophylaxis, Co-amoxiclav 25mg/kg/dose (Amoxicillin component) PO q12H

Inpatient:
Cloxacillin 50 mg/kg/dose IV q6H.


 


Co-trimoxazole (Trimethoprim component) 5mg/kg/dose PO q12H

OR


Doxycycline:

8-11 years: 4.4mg/kg/dose PO q24H on Day 1 then 2.2mg/kg/dose (can increase up to 4.4mg/kg/dose) PO q24h thereafter for 2-4 weeks

>12 years: 200mg q24H on Day 1 then 100mg q24H thereafter (can increase to 200mg)  for 2 -4 weeks
 



If liver function normal, can consider combination of:

Rifampicin 10mg/kg/dose PO q12H

AND

Fusidic acid 10mg/kg/dose PO q8H


Streptococcus pneumonia
Haemophilus Influenza
 

Outpatient:                                        

Co-amoxiclav 25mg/kg/dose (Amoxicillin component) PO q12H
for 4 weeks

Inpatient:
Co-amoxiclav 25-30mg/kg/dose (Amoxicillin component) IV q8H for 2 weeks


Cefuroxime 15mg/kg/dose PO q12H for 2 weeks

 

Cefuroxime 30mg/kg/dose IV q8H for 2 weeks


 
 
Pseudomonas aeruginosa

1st isolate:
Ciprofloxacin 20 mg/kg/dose PO q12H
(max dose 750 mg q12H)
+
Nebulised Gentamicin / Amikacin  for 3 months

Re-culture the sputum after 3 weeks.
If positive:
Ceftazidime 50 mg/kg/dose IV q8H (max 9 gm/day)
AND
Amikacin 30 mg/kg/dose IV q24H (max 2 gm) (Amikacin level) for 2 weeks

 
Precaution: Use of quinolones in paediatric patients is associated with increased incidence of adverse reaction related to joint i.e. tendonitis, tendon rupture

If the repeat sputum is negative for PA, then stop the oral Ciprofloxacin and continue nebulized Amikacin / Gentamicin for a total of 3 months.

If there is a substantial pseudomonal free period (> 3 months), the patient is treated in same manner as 1st isolate.
 
Chronic Pseudomonas Infection (Defined as 3 positive cultures at least 2 months apart and within 1 year)
 

During exacerbation:

Outpatient: 
Ciprofloxacin 20 mg/kg/dose PO q12H
(max dose 750 mg q12H) for 2 weeks



Inpatient or elective tuning,
Ceftazidime 50 mg/kg/dose IV q8H (max 9 gm/day)
AND
Amikacin 30 mg/kg/dose IV q24H (max 2 gm) (Amikacin level)            OR                                           Gentamicin 10mg/kg/dose IV q24H           for 2 weeks.

Followed by nebulized Amikacin / Gentamicin for 3 months.



 










Piperacillin-Tazobactam 100mg/kg/dose of piperacillin IV q8H

OR                                            Meropenem 40mg/kg/dose IV q8H

 

AND

 

Amikacin 30 mg/kg/dose IV q24H (max 2 gm) (Amikacin level)            OR                                           Gentamicin 10mg/kg/dose IV q24H           for 2 weeks.


Polymyxin B (Resistant):
< 2 years old: 0.75 - 2 mg/kg/dose IV q12h over 60-90 min
> 2 years old : 0.75 - 1.5 mg/kg/dose IV q12h over 60-90 min












Aztreonam 75 mg/kg IV q8H (max 8 gm/day)

Tobramycin 10 mg/kg/day IV q24H (max 600 mg/day).
 
Once chronic infection is established, there is a trend for the pseudomonas to become mucoid and more resistant to antibiotics. The aim of further treatment is to reduce the colony numbers in order to suppress the inflammatory response.




For chronically colonized patient, alternating monthly treatment of nebulized antibiotics (Gentamicin / Amikacin / Colistin) for 3 months i.e. Neb Gentamicin /Amikacin/ Gentamicin OR Neb Amikacin /Colistin/ Amikacin

 
Burkholderia Capecia complex

 
Ceftazidime 50 mg/kg/dose IV q8H (max 9 gm/day)
AND
Meropenem 40mg/kg/dose IV q8H (max 2 gm q8H)
for 2 weeks 


 

Chronic Burkholderia Capecia complex:

Doxycycline:

8-11 yrs: 4.4mg/kg/dose PO q24H on Day 1 then 2.2mg/kg/dose (can increase up to 4.4mg/kg/dose) PO q24H thereafter for 2-4 weeks

>12 yrs: 200mg q24H on Day 1 then 100mg q24H thereafter (can increase to 200mg)  for 2 -4 weeks

 

Neb Meropenem:

6-12 years: 125mg q12H

>12 years : 250mg q12H
 


Stenotrophomonas maltophilia

Outpatient:                                               Co-trimoxazole (Trimethoprim component) 5mg/kg/dose PO q6-12H
for 4 weeks.


 

 

Inpatient:
Co-trimoxazole (Trimethoprim component) 5 mg/kg/dose IV q6-12H


OR                                                 Levofloxacin 8-10 mg/kg/dose IV q12H

OR

Ceftazidime 50 mg/kg/dose IV q8h


 

Levofloxacin 8-10mg/kg/dose PO q12H

Doxycycline:

8-11 years: 4.4mg/kg/dose q24H on day 1 then 2.2mg/kg/dose (can increase up to 4.4mg/kg/dose) q24H thereafter for 2-4 weeks

>12 years: 200mg q24H on day 1 then 100mg q24H thereafter (can increase to 200mg)  for 2 -4 weeks 
 






 
MRSA

 

Outpatient:                              

Rifampicin 10 mg/kg/dose PO q12H AND                                                  

Co-trimoxazole (Trimethoprim component) 5mg/kg/dose PO q12H    for 2 weeks

Clindamycin (community acquired) 10mg/kg/dose PO q8H


Inpatient:                                   
Vancomycin 15mg/kg/dose IV q8H
 

Rifampicin 10 mg/kg/dose PO q12H

AND

Sodium Fusidate 10 - 15 mg/kg (250 - 500 mg) PO q8H
for 2 weeks

 






Resistance/ Treatment failure: Linezolid used in isolation for 2 weeks.
< 12 years: 10 mg/kg/dose q8H
> 12 years: 600 mg q12H
 
Surface swabs are taken for surveillance which includes right and left nostril, inguinal and sputum.

For MRSA nasal carriage: Topical Mupirocin / Bactroban to anterior nares. Patients will have to use Chlorhexidine wash on the skin once daily for 5 days.

Following treatment, sputum samples are obtained and repeated bi-monthly.
If positive on 2nd screen, oral treatment is repeated.
If remains positive following 2 full courses of oral treatment or during an infective exacerbation, then consider admission IV Vancomycin for 14 days.

Allergy Bronchopulmonary Aspergilosis

Prednisolone 2 mg/kg/day for 2 weeks, reduced to 1 mg/kg/day for 2 weeks, then alternate 1 mg/kg/day for 2 weeks.
Wean slowly over next 4 months reducing dose by 2.5 mg / 5 mg every 2 weeks.

AND


Itraconazole
1 month - 12 years: 5 mg/kg/dose PO q12h (max 200 mg q12H)
> 12 years: 200 mg q12H                   (stopped 2-4 weeks after the oral steroids are finished)

Nebulised Amphotericin B (non-liposomal) may be used in difficult cases after physiotherapy:
< 10 years: 5 mg q12H
> 10 years: 10 mg q12H

Pulsed Methylprednisolone 
10 - 15 mg/kg/dose (max 1gm/dose) IV q24H for 3 days every month.








Voriconazole as a 2nd line agent for patients who have not responded to or cannot tolerate twice daily Itraconazole:
2-11 years: 9 mg/kg/dose (max 350 mg) q12H
12-14 years:
< 50 kg – 9 mg/kg/dose (max 350 mg) q12H
> 50 kg – 400 mg q12H for 2 doses then 200 mg q12H (max 300 mg q12H)
15 years and above:
< 40 kg – 200 q12H for 2 doses then 100 mg q12H (max 150 mg q12H)
> 40kg – 400 mg q12H for 2 doses then 200 mg q12H (max 300 mg q12H)



The response to treatment is monitored by checking pulmonary function tests, CXRs and watching IgE titre as this should fall over time to more normal levels.









Monitor liver function. 
 
Invasive Aspergillus


IV Amphotericin (deoxycholate) 0.5 -1.0mg/kg/dose q24H




 
IV Voriconazole 9mg/kg/dose IV q12H for 2 doses, followed by 8mg/kg/dose IV q12H