Outpatient treatment of serious community-acquired pediatric infections using once daily intramuscular ceftriaxone

Pediatric patients with serious infections are usually hospitalized for parenteral antibiotic treatment. We studied prospectively 74 pediatric patients with community-acquired serious infections and used once daily intramuscular ceftriaxone. Seventeen patients (23%) were initially hospitalized and 57 (77%) patients were treated entirely as outpatients. An initial intramuscular dose of 75 mg/kg was followed by daily doses of 50 mg/kg (maximum, 1.5 g). Infections treated included periorbital/buccal cellulitis, other cellulitis, urinary tract infections, pneumonia, osteomyelitis, mastoiditis, suppurative arthritis and orbital cellulitis. Organisms were recovered from cultures of 37 (50%) patients and 6 (8%) patients were bacteremic. Bacteria included Gram-positive (mostly Staphylococcus aureus) and Gram-negative (mostly enteric bacilli and Haemophilus influenzae organisms). No serious side effects were observed. Of 74 patients 72 (97%) were cured and improvement was usually observed within 24 hours. Two patients did not improve: one with chronic Pseudomonas mastoiditis; and one with lung abscess. Based on previous experience it is estimated that 376 hospitalization days were saved. All 72 successfully treated patients and their parents resumed normal activity within 72 hours of starting therapy. Our data suggest that ceftriaxone can be used for outpatient treatment of some infectious diseases.     

Human herpesvirus 6 infection in febrile infants ninety days of age and younger

BACKGROUND: The importance of human herpesvirus 6 (HHV-6) as a pathogen in febrile infants 相似文献   

Once daily ceftriaxone and gentamicin for the treatment of febrile neutropenia.

AIMS: To evaluate the pharmacokinetics of once daily (OD) gentamicin and its effectiveness as part of an OD regimen for the empirical treatment of febrile neutropenia in children with cancer. SUBJECTS: 59 children aged 6 months to 16 years (mean (SD) 5.7 (4) years) with febrile neutropenia (neutrophil count < 0.5 x 10(9)/l) after chemotherapy. METHODS: Over one year, 113 febrile neutropenic episodes were treated empirically with an OD antibiotic regimen of ceftriaxone (80 mg/kg; maximum 4 g) and gentamicin (7 mg/kg; infused over 60 minutes, no maximum). The patients were assessed after 48 hours. RESULTS: 86 of the 113 episodes settled with the first line antibiotic regimen. In 29 episodes, blood cultures identified a causative bacterial pathogen; for 17 of these, the first line antibiotic regimen was adequate; in four episodes, although the episode settled, ceftriaxone was replaced by a more appropriate antibiotic and OD gentamicin was continued; in the remaining eight episodes, a glycopeptide antibiotic was deemed necessary. There was no failure of treatment in organisms sensitive to gentamicin, including Pseudomonas aeruginosa. In 27 episodes (24%), resolution was obtained by the empirical introduction of a second line regimen of ceftazidime and a glycopeptide antibiotic, and/or amphotericin. Gentamicin concentrations were measured in 110 episodes and they were all below the 24 hour line indicating that there was no need to change the dosing interval. In two episodes (2%), serum creatinine rose transiently by more than 50% of the baseline concentration. Although there was no vestibular toxicity, three of 30 children who underwent pure tone audiometry reported high frequency hearing loss in one ear. CONCLUSION: OD gentamicin can be used safely and effectively to treat febrile neutropenia in children with cancer. When used for a short period (< 5 days), in children not receiving other nephrotoxic drugs and who have normal serum creatinine, serum gentamicin estimations are unnecessary.     

Outpatient therapy of serious pediatric infections with ceftriaxone

Convalescent outpatient parenteral antibiotic therapy with ceftriaxone was evaluated in an uncontrolled study of 101 children with documented serious bacterial infections, including meningitis. Criteria for outpatient therapy were established to assure that risks of complications from the illness were minimal at the time of discharge from the hospital. Daily physician visits and motivated, capable parents were considered essential in outpatient management. Ceftriaxone was given once daily to children with non-central nervous system infections and once or twice daily intravenously to children with meningitis. The mean durations of therapy for children with non-central nervous system infections and with meningitis were 2.4 and 4.6 days, respectively. No child enrolled in this study was readmitted to the hospital for medical or social reasons. Probable complications of treatment included diarrhea in 13% of children with meningitis and in 6% of children with non-central nervous system infections. One child with meningitis developed pseudomembranous colitis. For children who are infected with bacteria that are highly susceptible to ceftriaxone, single daily dose outpatient therapy is a reasonable option for management if a good clinical response to initial treatment is demonstrated and the risks of complications of the disease process are negligible.     

Unpredictability of serious bacterial illness in febrile infants from birth to 1 month of age.

BACKGROUND: A prior study (N Engl J Med. 1993; 329: 1437-1441) produced an effective screen to identify 1-to 2-month-old febrile infants (FIs) who are at low risk of having a serious bacterial illness (SBI). Because of anticipated differences in the epidemiological features of febrile illnesses, that Philadelphia protocol was not applied to FIs younger than 1 month. OBJECTIVES: To describe the epidemiological features of febrile illness in neonates from birth to 1 month of age and to determine the applicability to this population of the Philadelphia screen for identifying FIs at low risk for SBI. DESIGN: A 36-month consecutive cohort study. SETTING: An urban pediatric emergency department. PARTICIPANTS: Infants aged from 3 to 28 days old with temperatures of 38 degrees C or higher. INTERVENTIONS: Following full evaluation for SBI, all FIs, pending results of bacterial cultures, were admitted to the hospital and empirically administered antibiotics. After their illnesses resolved, the medical records of all FIs were reviewed. At that time, the Philadelphia protocol (originally developed for 1- to 2-month-old FIs) was applied and retrospectively judged for safety and efficacy. RESULTS: Of the 254 FIs enrolled, 32 (12.6%) had an SBI. The spectrum of bacterial and nonbacterial diseases closely approximated that described in 1- to 2-month-old FIs. When the Philadelphia protocol was applied to all 254 FIs, 109 (42.9%) would have been identified as at low risk for bacterial disease. Included in that group are 2 FIs with bacterial urinary tract infection, 2 FIs with bacteremia, and 1 FI with bacterial gastroenteritis. CONCLUSIONS: The cause of febrile illnesses in neonates (infants younger than 1 month) approximates that of FIs 1 to 2 months of age. Unlike that for older 1- to 2-month-old FIs, however, the Philadelphia protocol lacks the sensitivity and negative predictive value to identify neonates at low risk for SBI.     

Absorption of phenobarbital after the intramuscular administration of single doses in infants.

Blood concentrations of phenobarbital, following an intramuscular administration of a single large dose of approximately 10 mg/kg, were studied in 39 infants. A rapid rise was obtained with a mean concentration of 9.30 mug/ml at 30 minutes, 12.76 mug/ml at 90 minutes, and a mean peak concentration of 13.28 mug/ml, which was reached in most cases within 2 hours of injection or less. Cerebrospinal fluid values in 13 patients averaged half the blood phenobarbital concentrations.     

Test characteristics of the respiratory syncytial virus enzyme-linked immunoabsorbent assay in febrile infants < or = 60 days of age

The test characteristics of rapid tests for respiratory syncytial virus (RSV) in infants may differ from older children secondary to a lower likelihood of previous illness with RSV. Our main goal was to establish the test characteristics of the RSV Abbott Testpack (TP) enzyme-linked immunoabsorbent assay (EIA) in febrile infants < or = 60 days of age. Our secondary goal was to determine the likelihood of RSV given a particular clinical syndrome and a negative or positive EIA. A prospective sample of infants with a temperature > or = 38.0 degrees C was evaluated during 2 successive RSV seasons. Conventional tissue and shell vial viral cultures were utilized as the reference standard. The RSV Abbott Testpack EIA had a sensitivity of 75% (95% CI 60-90%), a specificity of 98% (95% CI 96-100%), a positive predictive value of 89% (95% CI 77-100%), a negative predictive value of 95% (95% CI 91-98%), a likelihood ratio for a positive test of 35.5 (95% CI 11.4-110.7), and a likelihood ratio for a negative test of 0.26 (95% CI 0.14-0.47). Even with a negative EIA, patients with lower and upper respiratory tract illness still had a 22.3% and 5.5% chance of harboring RSV, respectively. The RSV Abbott Testpack is a useful diagnostic tool in the detection of RSV in febrile infants but has limitations. During months typically associated with RSV disease, a positive RSV TP indicates a high likelihood of illness, but clinicians should be wary of false negatives.     

Oral ciprofloxacin vs. intramuscular ceftriaxone as empiric treatment of acute invasive diarrhea in children

BACKGROUND: Acute invasive diarrhea is a potentially serious condition in children. Because of the increasing resistance of enteric pathogens to commonly used oral antibiotics, intramuscular ceftriaxone has become the routine drug in the treatment of acute invasive diarrhea requiring an emergency visit in southern Israel. The inconvenience of this parenteral regimen created an increased need for oral pediatric formulations for the treatment of invasive diarrhea. OBJECTIVES: To evaluate the efficacy and safety of a suspension formulation of ciprofloxacin in the treatment of acute invasive diarrhea in infants and children. PATIENTS AND METHODS: From July 1996 through December 1997, 201 evaluable children ages 6 months to 10 years (35% <1 year; 70% <3 years) presenting with acute invasive diarrhea at the Pediatric Emergency Room were randomized to receive either ciprofloxacin suspension (10 mg/kg twice a day + im placebo; n = 95) or im ceftriaxone (50 mg/kg/day + placebo suspension; n = 106) for 3 days in a double blind manner. Stool cultures for Shigella, Salmonella, Campylobacter spp. and diarrheagenic Escherichia coli were obtained on Days 1, 3, 4 to 5 and 21 +/- 5. Clinical response and safety were assessed on Days 1, 2, 3, 4 to 5 and 21 +/- 5. RESULTS: We isolated 127 pathogens from 121 (60%) patients: 73 (57%) Shigella; 23 (18%) Salmonella; 18 (14%) E. coli; and 13 (10%) Campylobacter. Overall bacteriologic eradication on Day 4 to 5 was 99% for Shigella, 77% for Salmonella and 77% for Campylobacter, with no difference between the 2 groups. Clinical cure or improvement was observed in 100 and 99% of the ciprofloxacin and ceftriaxone groups, respectively. Serum ciprofloxacin values determined on Day 3 of the treatment were higher in the majority of patients than were the MIC50 and MIC90 values for the Shigella and Salmonella spp. isolated. Possible drug-related adverse events occurred in 13 patients [ciprofloxacin, 8 (8%); ceftriaxone, 5 (4.7%)] and were mild and transient. Joint examination was normal during and after completion of therapy in all patients. CONCLUSION: Oral ciprofloxacin was as safe and effective as intramuscular ceftriaxone for the empiric treatment of acute invasive diarrhea in ambulatory pediatric patients requiring an emergency room visit.     

Improved outcome at 28 days of age for very low birth weight infants treated with a single dose of a synthetic surfactant

Two identical double-blind, controlled, randomized trials were initiated to determine whether the administration of a single 5 ml/kg dose of a synthetic surfactant (Exosurf Neonatal), soon after the delivery of infants with birth weights 700 to 1350 gm, would improve rates of survival without bronchopulmonary dysplasia. Both trials were terminated before enrolling their planned sample sizes because of the availability of Exosurf under the provisions of a Treatment Investigational New Drug program. We report the combined results of these trials. Study infants were stratified according to birth weight and gender before random assignment to a treatment regimen. One hundred ninety-two infants received Exosurf and 193 received an air placebo. The study groups were similar when a variety of demographic features describing the mothers, their pregnancies, the circumstances of the births, and the infants were compared. Exosurf-treated infants required significantly less oxygen and respiratory support during the first 3 days of life in comparison with the air-treated infants. Fewer infants in the Exosurf group had pulmonary interstitial emphysema (26 vs 13; p = 0.028). In the Exosurf group, there was a significant reduction in the combined outcome, neonatal death or survival with bronchopulmonary dysplasia (57 vs 39; p = 0.042), and there was a significant increase in rates of survival without this disease (128 vs 137; p = 0.042). There were no differences between treatment groups in the incidences of a variety of complications of prematurity, including apnea, patent ductus arteriosus, intraventricular hemorrhage, and necrotizing enterocolitis. We conclude that improvements in respiratory physiology after a single prophylactic dose of Exosurf result in an increased likelihood of neonatal survival without bronchopulmonary dysplasia.     

Once-daily intramuscular ceftriaxone in the outpatient treatment of severe community-acquired pneumonia in children

Ceftriaxone, a broad spectrum third-generation cephalosporin with a half-life of six to eight hours, was evaluated prospectively in 147 children with severe community-acquired bacterial pneumonia during the period 11/15/88-5/15/89. Thirty-nine of the children had been unsuccessfully treated with vanous oral antibiotics prior to admission [corrected]. All the patients were initially hospitalized and started on once a day intramuscular ceftriaxone. Mean duration of ceftriaxone therapy was five days. Pathogens were recovered from blood cultures of 17 (11.6%) patients and included S. pneumoniae (13 patients), H. influenzae (three, all resistant to ampicillin) and S. viridans (1) [corrected]. All isolates were sensitive to ceftriaxone. An additional patient had L. pneumophila diagnosed by serology. Cure was achieved in 142 (96.6%) patients; improvement was usually observed within 24-48 hours. After 48 hours, 121 (82.2%) children could be discharged and continued the therapy on ambulatory basis. Based on previous experience we estimated that 383 hospitalization days were saved. No serious side effects were observed. Five patients were considered therapeutic failures; two of them developed empyema and one of them required repeated drainage procedures. A third patient experienced a relapse of pneumonia shortly after completion of therapy. The other two remained febrile for more than seven days; their subsequent improvement was unrelated to the antibiotic therapy, suggesting a viral or mycoplasmal syndrome. Our data suggest that once daily intramuscular ceftriaxone can be successfully used for the outpatient treatment of most community-acquired severe bacterial pneumonias in children. In our opinion it represents the treatment of choice for patients who failed treatment with other antimicrobials and are clinically stable enough not to require hospitalization.