Neobook — clinical reference

Septicaemia

Respiratory infections

ENT and eye

Cardiovascular system

Central nervous system

Fungal infections

Gastro-intestinal infections

Musculoskeletal system

Parasitic infections

Sexually transmitted infections

Skin/soft tissue infection

Tuberculosis

Renal

Viral infections

Adapted from Essential Drugs List of South Africa, South African medicines formulary and Antimicrobial Recommendations for Red Cross Children’s Hospital (RCCH) and Tygerberg Children’s Hospital (TCH).

Before using this prescription list please note that this is just a reference to drug dosage in children only and therefore dosage may be different in neonates. There may be different dosage for different indications. NB: Before prescribing first check reference textbooks for:

Correct dose for neonates
Dosage changes for specific indications not mentioned
Contraindications for prescribing drug
Adverse effects of drug
Drug interactions
Max dosages in children

Septicaemia

SEPTICAEMIA

Community - acquired

Hospital - acquired

1^st line: Ampicillin 50 mg/kg/dose 6 hourly IV + Gentamicin 7.5 mg/kg/dose once daily IV
If intrinsic renal dysfunction is present, Ceftriaxone 50 mg/kg/dose once daily IV
PLUS Cloxacillin 50 mg/kg/dose 6 hourly IV if staphylococcal infection suspected.
Note: Substitute with Vancomycin 15mg/kg 8hrly if MRSA suspected.

2^nd line: Cefuroxime 25mg/kg/dose 6H PLUS Amikacin 15mg/kg IV once daily
3^rd line: Meropenem 20mg/kg/dose 8H IV PLUS Vancomycin 15mg/kg 8hrly. (Meropenem 40mg/kg/dose 8H if meningitis suspected.)

Respiratory infections

RESPIRATORY INFECTIONS
Community acquired Pneumonia
0-2 months of age	Ampicillin 50 mg/kg/dose 6 hourly IV + Gentamicin 7.5 mg/kg/dose once daily IV
> 2 months years of age	Ambulant: Amoxicillin 30 mg/kg /dose 8 hourly PO x 5-7 days Hospitalised: Ampicillin 50 mg/kg/dose 6 hourly IV
PLUS	Gentamicin 7.5 mg/kg/dose once daily IV in severe pneumonia, HIV-infected and severely malnourished children. Cloxacillin 50 mg/kg/dose 6 hourly IV if staphylococcal infection is suspected. Erythromycin 10 mg/kg/dose 6 hourly PO x 10-14 days if atypical organisms (e.g. mycoplasma or chlamydia) are suspected. Bactrim 5mg/kg/dose of trimethoprim component 6H if PJP suspected x 21 days.
Hospital acquired Pneumonia	2^nd line: Piptaz 50mg/kg/dose 6H PLUS Amikacin 15mg/kg IV once daily ADD Cloxacillin, Erythromycin, Bactrim if indicated Note: Substitute Cloxacillin with Vancomycin 15mg/kg 8hrly if MRSA suspected 3^rd line: Meropenem. 20mg/kg/dose 8H IV PLUS Vancomycin 15mg/kg 8hrly
Pertussis	Erythromycin 10mg/kg/dose 6 hourly x 14 days
Pneumocystis pneumonia	Co-trimoxazole (dose according to trimethoprim component) 10 mg/kg IV loading dose followed by 5 mg/kg/dose 6 hourly IV or PO x 21 days At the time of initiating treatment for pneumocystis pneumonia add prednisone 1-2 mg/kg/dose daily PO x 10-14 days or until no longer hypoxic, then taper over 1 week

ENT and eye

ENT AND EYE
Acute otitis media	Amoxicillin 30 mg/kg/dose 8 hourly or 45 mg/kg/dose 12 hourly PO x 5-7 days Children ≤2 years of age, HIV-infected children or recurrent cases x 7-10 days. Treatment failure: high-dose Co-Amoxiclav 15mg/kg/dose + Amoxicillin 15mg/kg/dose 8hourly PO x 5-7 days OR Ceftriaxone 50mg/kg/dose once daily IV/IM x 3 days. Considered referral to ENT specialist for tympanocentesis or grommets for treatment failure, recurrent infections or hearing loss.
Chronic Suppurative OM	1% acetic acid eardrops 3-4 drops 6hrly, with dry mopping for 4 weeks
Pharyngotonsillitis	Phenoxymethylpenicillin <25 kg: 250mg 12 hourly; >25 kg: 500mg 12 hourly PO x 10 days
Conjunctivitis	Chloramphenicol eye ointment 4 hourly, plus frequent eye irrigation with normal saline. Gonococcal (neonate): Add Ceftriaxone 25mg/kg/dose as a single dose IV/IM Chlamydial (neonate): Add Erythromycin 10 mg/kg/dose 6 hourly PO x 14 days
Sinusitis (acute bacterial)	Amoxicillin 30 mg/kg/dose 8 hourly PO x 10 days
Dental abscess	Co-Amoxiclav 15 mg/kg/dose 8 hourly PO × 5 days Severe cases: Cefuroxime 50mg/kg/dose 8H + Metronidazole 7.5mg/kg/dose 8H × 5 days Consider referral to a dental surgeon or ENT specialist.
Diphtheria	Benzylpenicillin 50 000 U/kg/dose 6 hourly IV x 7-10 days Note: Patient should be isolated and elimination of the organism documented by two consecutive negative cultures of throat swabs after completion of treatment.

Cardiovascular system

CARDIOVASCULAR SYSTEM
Acute rheumatic fever	Phenoxymethylpenicillin <25kg: 250mg; •25kg: 500mg 12H PO x 10 days For penicillin-allergic patients, use Erythromycin 10mg/kg/dose 6H PO × 10 days
Infective Endocarditis Empiric therapy: (native valve) Directed therapy: (native valve) See Antimicrobial Recommendations for Red Cross Children’s Hospital (RCCH) and Tygerberg Children’s Hospital (TCH) on website. Empiric & direct therapy: (prosthetic valve)	Ideally, one should wait for confirmation of the diagnosis and identification of an organism before commencing therapy for infective endocarditis, but in patient presenting with severe disease, empiric therapy should be commenced.
	Pen G IV, 50 000 units/kg/dose, 6 hourly for 4 weeks, PLUS Cloxacillin IV 25 mg/kg/dose 6 hourly for 4 weeks, PLUS Gentamicin IV 1,5 mg/kg/dose 8 hourly for 4 weeks
	See Antimicrobial Recommendations for Red Cross Children’s Hospital (RCCH) and Tygerberg Children’s Hospital (TCH) on website.
	All cases of suspected prosthetic valve endocarditis should be discussed with a cardiologist before therapy is commenced.

Central nervous system

CENTRAL NERVOUS SYSTEM
Bacterial Meningitis Duration of therapy:	< 3mo: Group B Strep / E.Coli / Listeria Monocytogenes AMPICILLIN 50mg/kg 6H IV, plus CEFOTAXIME 50mg/kg 6H IV. > 3mo: Streptococcus pneumoniae, Neisseria meningitides, Haemophilis influenza Empiric therapy : Ceftriaxone 100mg/kg/dose daily IVI When pathogen cultured: Treat according to sensitivities. H. influenzae & S. pneumoniae - treat for 10 days N. meningitidis - treat for 5- 7 days Group B Streptococcus - treat for 14 days L. monocytogenes - treat for 21 days Gram-negatives (neonates) - treat for 21 days Note: In neonates, or in patients receiving concomitant intravenous calcium-containing fluids, Ceftriaxone should be switched to Cefotaxime 50mg/kg/dose 6hourly IV. If <2 months of age Ampicillin 50mg/kg/dose 6 hourly IV should be added for at least 48 hours until Listeria infection is excluded. Dexamethasone 0.15mg/kg/dose 6 hourly IV for 2 days is added in children >2 months of age with suspected bacterial meningitis and should be given immediately before or simultaneous to the first antibiotic infusion.
Herpes simplex encephalitis	0-12 years of age: Aciclovir 20 mg/kg/dose 8 hourly IV x 14-21 days >12 years of age: Aciclovir 10 mg/kg/dose 8 hourly IV x 14-21 days Note: If diagnoses is considered, begin treatment before confirmation of HSV infection. In neonates with HSV encephalitis, treatment duration is at least 21 days and treatment should only be stopped once CSF herpes simplex PCR is negative.
Cryptococcal meningitis	See Essential Drugs List of South Africa. Manage all cases in consultation with the infectious diseases unit. Amphotericin B only available at tertiary care.
Neurocysticercosis	Calcified cysticerci and a single dying lesion visible on CT scan require no treatment or monitoring. Patients with multiple dying cysts are assumed to have active disease and require treatment. Albendazole oral 5mg/kg/dose 8 hourly for 5 days (Max: 800mg/day). Prevention of neurological manifestations: In massive infestations, cysticidal therapy may trigger an inflammatory response. Delaying therapy and adding corticosteroids may lessen the risk if started < 24 hours prior to Albendazole therapy. Dexamethasone IM 0.25–0.5 mg/kg/24 hours 6 hourly (Continue for the duration of the therapy). Follow with oral therapy as soon as possible to take oral: prednisone 1 mg/kg/day Continue for the duration of the Albendazole therapy.

Fungal infections

FUNGAL INFECTIONS
Oral thrush	Nystatin suspension (100 000 IU/ml) 1 ml into the mouth 4 times a day Miconazole gel topically 3 times daily for severe thrush.
Severe oral or oesophageal candidiasis	Fluconazole 6 mg/kg/dose once daily PO x 14-21 days
Napkin area	Clotrimazole cream topically with napkin changes. Barrier cream such as zinc & castor oil cream for napkin dermatitis.
Systemic Candidemia	Amphoteracin B (See guidelines). Step down Fluconazole 6-12mg/kg/dose daily IV/PO

Gastro-intestinal infections

GASTRO-INTESTINAL INFECTIONS
Chronic Diarrhoea	Gentamicin 50mg/kg/day q4h (max 60mg per dose) PO for 3 days Metronidazole (Flagyl) 7.5mg/kg q8h PO for 5 days
Bacterial dysentery	Ciprofloxacin oral, 15 mg/kg/dose 12 hourly for 3 days. If ill and toxic or <3 months of age: Ceftriaxone 50mg/kg/dose once daily IV x 5 days Note: Exclude intussusception by history, examination and Abd sonar if indicated.
Cholera	Ciprofloxacin 20 mg/kg/dose as a single dose PO
Giardiasis	Metronidazole 7.5 mg/kg/dose 8 hourly PO x 5 days
Campylobacter	Erythromycin 10 mg/kg/dose 6 hourly for 7 days
Yersinia enterocolitica	Bactrim 5mg/kg/dose of trimethoprim component 6 hourly for 5 days
Amoebiasis	Metronidazole 15 mg/kg/dose 8 hourly x 10 days
Peritonitis	Benzylpenicillin 50 000 U/kg/dose 6 hourly IV + Gentamicin 7.5 mg/kg/ dose once daily IV + Metronidazole 7.5 mg/kg/dose 8 hourly IV
Typhoid fever	Ceftriaxone 50 mg/kg/dose once daily IV x 7-10 days (invasive Salmonella infection) An alternative is Ciprofloxacin 15 mg/kg/dose 12 hourly PO × 7-10 days
Worm infestation	Children 1–2 years of age: Mebendazole, oral, 100 mg 12 hourly for three days. Children > 2 years: Mebendazole, oral, 500 mg as a single dose immediately. Alternative: Albendazole 200 mg as a single dose.

Musculoskeletal system

MUSCULOSKELETAL SYSTEM
Acute osteomyelitis	Cloxacillin 50 mg/kg/dose 6 hourly IV Neonatal infections add cefotaxime 50 mg/kg/dose IV 8-6 hourly. Note: Refer to orthopaedics for possible surgical drainage. Once good clinical response change to oral antibiotics (according to sensitivities) and complete total of 6 weeks.
Septic arthritis	Neonates: Cloxacillin 50 mg/kg/dose 6H IV + Cefotaxime 50mg/kg/dose IV 8-6 hourly. Infants / children: Cloxacillin 50mg/kg/dose IV 6H + Cefotaxime 25-50mg/kg/dose 6H. Note: Refer to orthopaedics for possible surgical drainage. Once good clinical response change to oral antibiotics (according to sensitivities) and complete total of 4 weeks.

Parasitic infections

PARASITIC INFECTIONS
Hydatid disease	Albendazole 7.5 mg/kg/dose 12 hourly PO x 28 days, stop for 2 weeks and then repeat cycle for a total of 3 cycles
Malaria	See National Malaria Guidelines
Schistosomiasis/Bilharzia	Praziquantel 20 mg/kg/dose 12 hourly PO x 1 day (i.e. 2 doses)

Sexually transmitted infections

SEXUALLY TRANSMITTED INFECTIONS – All need to be investigated for sexual abuse
Bacterial vaginosis	Metronidazole 7.5mg/kg/dose 8H PO + amoxicillin 30mg/kg/dose 8 hourly PO x 7 days
Candidiasis	Nystatin cream OR 1% Clotrimazole cream OR 2% Miconazole cream applied intravaginally 8 hourly x 7 days
Gonorrhoea	Ceftriaxone IM as a single dose: <25 kg 125 mg; >25 kg 250mg
Chlamydia trachomatis	<8 years: Erythromycin 10-15 mg/kg/dose 6 hourly PO × 14 days >8 years: Doxycycline 100 mg twice daily PO x 7 days OR Erythromycin for 14 days Alternative is: Azithromycin 20 mg/kg/dose as a single dose PO (maximum dose 1 g)
Trichomonas vaginalis or Gardnerella vaginalis	Metronidazole 7.5mg/kg/dose 8 hourly PO x 7 days Adolescents: Metronidazole 2g PO as a single dose
Syphilis	Benzathine penicillin 50 000 u/kg/dose once weekly × 3 doses IM (max dose 2.4 MU) For penicillin-allergic patients: Children <8 years of age: Erythromycin 10-15 mg/kg/dose 6 hourly PO × 30 days Children >8 years of age: Doxycycline 2 mg/kg/dose 12 hourly PO × 14 days (maximum dose 100 mg)

Skin/soft tissue infections

SKIN / SOFT TISSUE INFECTIONS
Bite (animal or human)	Co-Amoxiclav 15 mg/kg/dose + Amoxicillin 15 mg/kg/dose 8 hourly PO x 5 days Refer to the section on post-exposure prophylaxis for rabies
Cellulitis	Localised or mild: Flucloxacillin 25 mg/kg/dose 6 hourly PO x 5–10 days Severe: Benzylpenicillin 25 000U/kg/dose 6H + Cloxacillin 50mg/kg/dose 6H IV x 5-10days If there is clinical improvement after 48 hours of treatment, consider changing to Co-Amoxiclav 15 mg/kg/dose 8 hourly PO × 5 days
Pediculosis (lice) and scabies	<6 months of age: 5% sulphur ointment twice daily × 3 days 6 months–2 years of age: ¼ strength Benzyl benzoate as a single application 2-12 years of age: ½ strength Benzyl benzoate as a single application >12 years of age: full strength Benzyl benzoate as a single application Tetmesol soap to wash body, clothes and linen
Superficial abscess	Surgical drainage alone may suffice. If surrounding cellulitis or systemically unwell, Cloxacillin IV or Flucloxacillin PO
Tinea capitis	Fluconazole 6 mg/kg/day x 2-3 weeks
Tick Bite Fever	Children >8 years of age: Doxycycline 2 mg/kg/dose 12 hourly PO x 1 day followed by Doxycycline 1 mg/kg/dose 12 hourly PO x 7 - 10 days Children <8 years of age: Doxycycline 2 mg/kg/dose 12 hourly PO x 2 days followed by Erythromycin 10 mg/kg/dose 6 hourly PO x 7 days OR Chloramphenicol 12.5 mg/kg/dose 6 hourly PO x 7 days

Tuberculosis

TUBERCULOSIS - See TB Drug Dosing Chart for Children <8 years of age (2013)

Renal

RENAL

Urinary Tract Infection

Out-patient: Co-Amoxiclav 15 mg/kg/dose + Amoxicillin 15 mg/kg/dose 8 hourly PO x 7 days OR Cefuroxime 10 mg/kg/dose 12 hourly PO × 7 days
If no refrigerator is available, Ciprofloxacin 15 mg/kg/dose 12 hourly PO x 7 days
Sick (Requiring admission): Gentamicin 7.5 mg/kg/dose once daily IV x 7-10 days
If intrinsic renal failure is present, Ceftriaxone 50 mg/kg/dose once daily IV x 7-10 days
Note: Measure renal function and gentamicin levels serially to monitor potential toxicity. If there is clinical improvement after 48 hours of intravenous treatment, consider changing to oral therapy for the remainder of 10 days. Nalidixic acid is not recommended for treatment as it is only an antiseptic

Viral infections

VIRAL INFECTIONS
Cytomegalovirus	Systemic infection (incl. pneumonitis, oesophagitis, colitis, encephalitis, chorioretinitis) Ganciclovir 5 mg/kg/dose 12 hourly IV × 14-21 days
Herpes simplex virus	Gingivo-stomatitis: Aciclovir 20 mg/kg/dose 6 hourly PO × 7 days
HIV infection	See ARV Drug Dosing Chart For Children
Influenza	Oseltamivir twice daily PO × 5 days, dosed according to dosage table.
	Children <1 year of age
	Premature neonates (<38 weeks)	1 mg/kg/dose twice daily
	Infants 0-12 months	3 mg/kg/dose twice daily
	Children 1-12 years of age
	15 kg or less	30 mg twice daily
	15-23 kg	45 mg twice daily
	24-40 kg	60 mg twice daily
	>40 kg	75 mg twice daily
Varicella	Aciclovir 20 mg/kg/dose 6 hourly PO × 7 days (maximum dose 800 mg) Only treat if immune-compromised or complicated (like pneumonia)

Infection and drug dosages

Drugs mentioned