Empiric Antibiotics for the Complex Febrile Child: When, Why, and What to Use

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There are multiple patient care scenarios where empiric antibiotics are indicated in the practice of pediatric emergency medicine. Patients with fever and neutropenia, ventriculoperitoneal shunt(s), cystic fibrosis, and short bowel syndrome are unique patient populations that are often instructed to seek further evaluation for any concerns of possible infection. When seen in the emergency department, fever is usually the presenting complaint; however, they may also present with more subtle signs and symptoms of infection that require prompt evaluation. This article briefly reviews these 4 unique patient populations as well as when, why, and what empiric antibiotics are often used to treat them.

Section snippets

Empiric Antibiotics in Patients with Fever and Neutropenia

Neutropenia can be congenital, idiopathic, and/or acquired in etiology. The causes of acquired neutropenia include infections, immune disorders, nutritional deficiencies, chemicals, and medications. Patients with fever and neutropenia are at risk for serious infection. Empiric antibiotics included in this section are based on guidelines for patients with cancer receiving chemotherapy but are applicable to most patients with fever and neutropenia regardless of etiology.

Patients with cancer are

Empiric Antibiotics for Patients with VP Shunt(s)

Cerebrospinal fluid (CSF) shunt placement is the most common pediatric neurosurgical procedure performed. As a result of very high complication rates, patients with VP shunts are frequently brought to the ED for evaluation of suspected malfunction. Although obstruction is the most common complication, infection is responsible for 20% to 25% of all shunt complaints [6]. Seizures, ventriculitis, meningitis, and subdural empyema are secondary problems that can develop as a result of shunt

Empiric Antibiotics in Patients with Cystic Fibrosis

Patients with cystic fibrosis (CF) often present to the ED for evaluation and treatment of pulmonary exacerbations. It is extremely important to diagnose and treat new or worsening infections to limit progression of chronic lung disease. Furthermore, a variety of factors make the eradication of respiratory pathogens in children with CF especially difficult (Table 2).

In early disease, infections are associated with acute respiratory complaints and new physical findings. Over time, a repeating

Empiric Antibiotics in Patients with Short Bowel Syndrome

Short bowel syndrome can result from congenital or acquired reasons. Congenital etiologies include gastroschisis, intestinal atresia, and midgut volvulus; and acquired etiologies include necrotizing enterocolitis or Crohn's disease. Long-term parenteral nutrition has resulted in improved long-term survival and quality of life in this patient population; for that reason, patients with short bowel syndrome require prolonged use of central venous catheters. Consequently, parenteral

Relevant Antibiotic Alerts

The US Food and Drug Administration (FDA) initiated a safety review of cefepime in November 2007 after concerns of increased mortality in patients treated with cefepime were raised in a published meta-analysis. In May 2008, the FDA announced it was continuing to review safety data concerning cefepime 22, 23. Additionally, the FDA initiated a safety review of linezolid in March 2007 after concerns of increased mortality in patients with catheter-related bacteremia and catheter site infections

Summary

Children with fever and neutropenia, VP shunt(s), CF, and short bowel syndrome frequently present in the ED with a complaint of fever with or without additional signs and symptoms. In addition to a thorough evaluation and stabilization of the patient, the ED physician is often responsible for initiating empiric antibiotics to treat suspected bacterial infections in these complex febrile children. The choice of a particular empiric antibiotic regimen may vary depending on the individual patient

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