Paediatric Acute care Guidelines PMH Emergency Department

Some children with common infections presenting to the emergency department may be deemed to be unsuitable for oral antibiotics (e.g. more severe disease; unable to tolerate or absorb oral antibiotics) yet well enough to be managed without inpatient hospital-care. The following guidelines have been developed so children with common presentations to the Emergency Department at PMH can access HiTH directly from ED for intravenous (IV) antibiotic therapy. Once HiTH therapy has been deemed appropriate by the admitting team consultant, children are reviewed by the HiTH Nursing Co-ordinator and accepted onto the HiTH program whenever possible. Discharge from ED will be contingent upon the availability of HiTH nursing staff and appropriately prepared home IV antibiotics.

HITH Admission Pathway from the Emergency Department 

Diagnosis of cellulitis, periorbital cellulitis, cervical lymphadenitis or UTI/pyelonephritis made by reviewing ED doctor
Patient clinically stable

Emergency Department Consultant confirms HiTH therapy is appropriate

ED doctor contacts HiTH nurse coordinator (ext 8379) between 0700 – 2100 to confirm HiTH availability

ED doctor contacts admitting specialty consultant to accept patient onto HiTH

Intravenous antibiotics charted as per HiTH antibiotic guidelines (max. TDS)
First dose to be administered in ED
Chart sent to pharmacy to order CIVAS (weekdays)

Chart normal saline flushes and adrenaline (not dispensed)
Oral stepdown antibiotic prescription provided to patient or HiTH nurse

Booked review or discharge plan confirmed with specialty team and patient prior to discharge

 

  • HiTH can offer up to three nursing visits per day, therefore a maximum frequency of TDS dosing can be prescribed, to be administered between the hours of 0800 and 2130. Where possible, less frequent dosing is preferred to facilitate greater numbers of HITH patients.
  • The following list provides recommended therapies for children with common infections. This list is not exhaustive for indications for HiTH management (see Antibiotic Guidelines for HiTH patients for further information). When patients are commenced on HiTH from ED and have microbiological specimens collected, these should be checked at 48 hours to confirm appropriate antibiotic selection for step-down. This is most relevant to UTI management.
Diagnosis / Indications for HiTH IV Antibiotic/s dosage and frequency  (1-4 days) Known MRSA colonisation / infection Subsequent oral antibiotic choice Usual total duration of therapy (IV + oral) 
Cellulitis Cephazolin 50mg/kg (max 2g) TDS

Trimethoprim/ sulphamethoxazole PO 4mg/kg (of trimethoprim component BD
OR 
ˆClindamycin PO/IV 10mg/kg TDS

Oral Cephalexin 12.5mg/kg (to a maximum of 500mg) QID
OR
Trimethoprim/ sulphamethoxazole PO 4mg/kg (of trimethoprim component) BD
 5 – 10 days
Periorbital cellulitis Ceftriaxone 100mg/kg (max 2 g) once daily

Please note this regime is for HiTH patients only – differs from hospital ChAMP guidelines

Ceftriaxone 50mg/kg (max 2g) once daily
AND 
ˆClindamycin PO/IV 10mg/kg TDS
OR
Trimethoprim/ sulphamethoxazole PO 4mg/kg (of trimethoprim component) BD

Oral Amoxycillin/clavulanic acid 25mg/kg (max 875mg amoxycillin component) BD  7 days
Cervical lymphadenitis Cephazolin 50mg/kg (max 2g) TDS Trimethoprim/ sulphamethoxazole PO 4mg/kg (of trimethoprim component) BD
OR 
ˆ
Clindamycin PO/IV 10mg/kg TDS
Oral Cephalexin 12.5mg/kg (to a maximum of 500mg) QID  7 days
UTI/ pyelonephritis Ceftriaxone 50mg/kg (max 2g) once daily  N/A Oral Cephalexin 12.5mg/kg (to a max of 500mg) QID
OR
Oral Amoxicillin/clavulanic acid 25mg/kg (max 875mg amoxycillin component) BD
 7-10 days
ˆOral clindamycin is very unpalatable unless a child can take capsules. Oral trimethoprim/sulphamethoxazole is preferred in younger children. If oral MRSA therapy is not tolerated, consider IV clindamycin. 

All dosing recommendations are for intravenous preparation of the drug in children with normal renal function aged >3 months old. Individual prescribers should know the common and uncommon drug associated toxicities. Monitoring should be performed as per ChAMP antimicrobial monographs. Additional monitoring may be required in certain clinical situations to monitor for drug related adverse events and clinical progress. Patients on HiTH for > 7 days require minimum weekly review by the managing team.

Please note:

  • These are empiric guidelines and may require adjustment in individual cases. It is recommended that deviation from these guidelines be discussed with the clinical microbiologist and/or infectious diseases consultant/fellow.
  • Children with a history of previous serious adverse reactions to IV antibiotics or mastocytosis are NOT suitable for home IV antibiotics. Children on beta-blockers need to be treated with caution as they may be resistant to adrenaline usage.
  • For oral step-down therapy:
    • For MRSA (colonisation, infection or risk factors), continue oral treatment with the same oral MRSA active agent that was used in the initial therapy. Oral trimethoprim/sulphamethoxazole (cotrimoxazole) is far more palatable in the syrup formulation than oral clindamycin. Small children usually prefer oral trimethoprim/sulphamethoxazole (cotrimoxazole) over clindamycin.
    • Please refer to complete ChAMP guidelines for oral step-down alternatives in delayed or immediate penicillin allergy.
  • All patients require an order of adrenaline to be charted (but not dispensed):
Weight band of child  Dose of Adrenaline
< 5 kg 0.05mL of 1:1000 Adrenaline (50 microg adrenaline)
5 – 10kg 0.1mL of 1:1000 Adrenaline (100 microg adrenaline) 
10 – 20kg EpiPen jnr (150 microg of adrenaline) 
> 20kg EpiPen (300 microg of adrenaline) 

References

Guideline Developed by: Ariel Mace (Ambulatory Care Fellow), Asha Bowen (Infectious Diseases Consultant) and Zoy Goff (Pharmacist)
External Review: Andrew Martin (Department of General Paediatrics)

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