Suspected Staphylococcus Aureus Skin and Soft Tissue Infections - Evaluation and Management in Neonates PDF

6/20/2016
SuspectedStaphylococcusaureusskinandsofttissueinfections:Evaluationandmanagementinneonates
OfficialreprintfromUpToDate
www.uptodate.com2016UpToDate
Author
SheldonLKaplan,MD
SectionEditor
MorvenSEdwards,MD
DeputyEditor
MaryMTorchia,MD
Alltopicsareupdatedasnewevidencebecomesavailableandourpeerreviewprocessiscomplete.
Literaturereviewcurrentthrough:May2016.|Thistopiclastupdated:Apr15,2016.
INTRODUCTIONTheevaluationandmanagementofsuspectedmethicillinresistantStaphylococcusaureus(MRSA)
skinandsofttissueinfections(SSTI)inneonates(28daysofage)willbereviewedhere.Generalaspectsofthe
managementofSSTItheevaluationandmanagementofMRSASSTIinchildrenolderthan28daystheepidemiology,
prevention,andcontrolofMRSAinfectionsinchildrenandthetreatmentofinvasiveMRSAinfectionsinchildrenandare
discussedseparately.
(See"Cellulitisanderysipelas".)
(See"Impetigo".)
(See"Infectiousfolliculitis".)
(See"Skinabscesses,furuncles,andcarbuncles".)
(See"SuspectedmethicillinresistantStaphylococcusaureusskinandsofttissueinfections:Evaluationand
managementinchildren>28days".)
(See"MethicillinresistantStaphylococcusaureusinfectionsinchildren:Epidemiologyandclinicalspectrum".)
(See"MethicillinresistantStaphylococcusaureusinchildren:Preventionandcontrol".)
(See"MethicillinresistantStaphylococcusaureusinchildren:Treatmentofinvasiveinfections".)
EVALUATION
HistoryandexaminationThehistoryandexaminationoftheneonatewithsuspectedS.aureusSSTIfocuson
considerationofothercausesofSSTIinneonates,particularlythosewithvesicopustularlesionsthatmayrequireother
typesofantimicrobialtherapythanS.aureusinfections(table1).(See"Vesiculobullousandpustularlesionsinthe
newborn".)
Importantaspectsoftheclinicalevaluationinclude:
Systemicsymptomsandsigns(eg,illappearance,fever/hypothermia,irritability,poorfeeding.
Riskfactorsforsepsisandherpessimplexvirus(HSV),whicharediscussedseparately.(See"Clinicalfeatures,
evaluation,anddiagnosisofsepsisintermandlatepreterminfants",sectionon'Maternalriskfactors'and"Clinical
featuresanddiagnosisofbacterialsepsisinthepreterminfant(<34weeksgestation)",sectionon'Riskfactors'and
"Genitalherpessimplexvirusinfectionandpregnancy".)
AssociatedfeaturesofcongenitalHSV,neonatalvaricellavirus,orcongenitalsyphilis(table2).(See"Neonatal
herpessimplexvirusinfection:Clinicalfeaturesanddiagnosis",sectionon'NeonatalHSV'and"Varicellazoster
infectioninthenewborn",sectionon'Neonatalvaricella'and"Congenitalsyphilis:Clinicalfeaturesanddiagnosis",
sectionon'Earlycongenitalsyphilis'.)
Laboratoryevaluation
WoundculturesWeobtainspecimensforGramstain,culture,andsusceptibilitytestingfromneonateswith
purulent/fluctuantskinlesions(ie,abscesses)ifpurulentmaterialcanbeobtained[13].
Gramstainidentificationofgrampositivecocciinclustersprovidesearlyindicationofstaphylococcalinfection,
whichcanhelpguideempirictherapy.
IfS.aureusisisolatedinbacterialculture,susceptibilitytestingisnecessarytodistinguishmethicillinresistantS.
aureus(MRSA)frommethicillinsusceptibleS.aureus[4].Insomelaboratories,methicillinresistancemaybe
detectedrapidlyusingcommerciallyavailablemoleculartestsforthemecAgenethatleadstomethicillinresistance.
(See"RapiddetectionofmethicillinresistantStaphylococcusaureus".)
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OtherstudiesOurapproachtoobtainingotherlaboratorystudiesandculturesinneonateswithsuspectedS.
aureusSSTIdependsuponthetypeofinfectionandassociatedclinicalfeatures:
NeonateswithmastitisTheevaluationofneonateswithmastitisisdiscussedseparately.(See"Mastitisand
breastabscessininfants,children,andadolescents",sectionon'Infants<2monthsofage'.)
Termneonateswithlocalizedpustulosis(picture1),nofever,andnoothersystemicsignsWegenerallydo
notobtainbloodculturesorothermicrobiologicstudiesunlessitisnecessarytodistinguishstaphylococcal
pustulosisfromothercausesofpustularlesions(table1)[5].Inotherwiseasymptomaticneonateswith
pustulosis,theGramstainishelpfulindistinguishingpustulosisfromotherconditions.IfHSVremainsa
possibility,theinfantshouldundergofullevaluationforHSV.(See"Neonatalherpessimplexvirusinfection:
Clinicalfeaturesanddiagnosis",sectionon'Evaluationanddiagnosis'.)
Pretermneonatewithlocalizedpustulosis(withorwithoutsystemicsigns)Weusuallyobtainbloodcultures.
Termorpretermneonateswithmultiplesitesofpustulosis,othertypesofSSTI(eg,cellulitis,abscess,
mastitis),fever,orothersystemicsigns/symptomsWeobtainbloodandurineculturesinallsuchpatients
andcerebrospinalfluid(CSF)culturesasclinicallyindicated(eg,fever/hypothermia,illappearing)[3].
IndicationsforCSFculturesinneonatesarediscussedseparately:
Pretermneonates(<34weeksgestation)(see"Clinicalfeaturesanddiagnosisofbacterialsepsisinthe
preterminfant(<34weeksgestation)",sectionon'Othercultures')
Term(>37weeksgestation)andlatepreterm(34to36weeksgestation)neonates<7days(see"Clinical
features,evaluation,anddiagnosisofsepsisintermandlatepreterminfants",sectionon'Earlyonset
sepsis')
Termandlatepretermneonates7daysofage(see"Evaluationandmanagementofthefebrileyoung
infant(7to90daysofage)")
SignificantCSFpleocytosiswithsterileCSFculturemaybeseeninassociationwithcommunityassociated
MRSAinfectioninneonates[3,5].Thepathogenesisofthepleocytosisisunclear.
MANAGEMENTAPPROACHThesafetyandefficacyoftopical,oral,andparenteraltherapyforcommunity
associatedmethicillinresistantS.aureusinfectionshavenotbeenwellevaluatedinneonates.Theapproachdescribed
belowisconsistentwiththatprovidedbytheInfectiousDiseasesSocietyofAmerica(IDSA)[1],whichisbasedupon
observationsfromareviewof126casestreatedbetween2001and2006attheauthor'sinstitution[3].Additional
considerationsincludetheincreasedriskofsepsisinneonates(giventheimmaturityoftheirimmunesystem)andthe
inabilitytoaccuratelypredictseriousbacterialinfectionaccordingtoclinicalfeaturesorclinicaldecisionrules.(See
"Strategiesfortheevaluationoffebrileyounginfants(7to90daysofage)",sectionon'Limitationsinneonates'.)
Localizedpustulosis
WellappearingfulltermneonatesWesuggestthatlocalizedpustulosis(picture1)infulltermneonateswithout
feverorothersignsorsymptomsofinfectionbetreatedwithtopicalantibiotictherapy(eg,mupirocinthreetimes
dailyfor5to10days)intheoutpatientsetting[1,3]closefollowupofsuchpatientsisimperative[3].(See
'Responsetotherapy'below.)
Preterm,lowbirthweightneonatesWerecommendthatlocalpustulosisinpretermorverylowbirthweight
infantsbetreatedparenterallyatleastuntilbacteremiaisexcluded[1].
SSTIotherthanlocalizedpustulosisWehospitalizepreterm/verylowbirthweightneonatesandtermneonateswith
SSTIotherthanlocalizedpustulosis(eg,multiplesitesofpustulosis,mastitisandothersitesofcellulitis,abscess)for
closemonitoringandparenteralantimicrobialtherapy[3].Infants28daysareatincreasedriskforinvasiveinfection.
Suchneonatestypicallyhaveundergoneevaluationforoneormoreconcomitantseriousbacterialinfection(eg,
bacteremia,urinarytractinfection,meningitis,osteoarticularinfection)andaretreatedwithparenteralantimicrobialtherapy
until48hourcultureresultsareavailable.
Inadditiontoprovisionofparenteralantimicrobialtherapy,werecommenddrainageofpurulentorfluctuantlesions(eg,
cutaneousabscess).
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ANTIMICROBIALTHERAPY
InitialparenteraltherapyEmpiricparenteralantibioticsforsuspectedstaphylococcalSSTIinneonatesshouldbe
baseduponthelocalsusceptibilitypatternofcommunityassociatedS.aureusisolates.Whentheetiologicagentand
susceptibilityareknown,antimicrobialtherapycanbenarrowedasindicated.
Forneonateswithsuspectedstaphylococcalinfectionlimitedtotheskinandsofttissues,weprovideinitialempiric
coverageformethicillinresistantS.aureus(MRSA)withvancomycin,clindamycin,orlinezolid[1,3].Incommunities
whereMRSAislessprevalent,initialempiriccoverageformethicillinsusceptibleS.aureus(eg,nafcillin,oxacillin)isan
alternative(table3).
Forinfantswithsuspectedstaphylococcalinfectionwhoarefebrile,haveothersystemicfindings,orareadmittedtothe
hospital,itisusuallynecessarytoaddcoverageforotherneonatalpathogens(eg,gentamicinorcefotaximeforenteric
gramnegativepathogens).Thecombinationofvancomycinpluseithercefotaximeorgentamicinprovidesadequate
empirictherapyforpossiblegroupBstreptococcalcellulitis,butisnotappropriateforsepsisormeningitis.(See"Clinical
features,evaluation,anddiagnosisofsepsisintermandlatepreterminfants",sectionon'Etiologicagents'and
"Managementandoutcomeofsepsisintermandlatepreterminfants",sectionon'Initialempirictherapy'and"GroupB
streptococcalinfectioninneonatesandyounginfants",sectionon'Antimicrobialtherapy'.)
Durationoftherapy
IsolatedSSTIThetotaldurationoftherapyforstaphylococcalSSTIinneonatesdependsuponclinicalresponsea
totalof7to14daysisusuallyadequateiftherearenocomplications[3].
WecontinueparenteraltherapyforinfantswithisolatedSSTIatleastuntilallofthefollowingcriteriaaremet:
Resolutionofsystemicsymptomsandfever
Improvementinotherclinicalfindings
Antibioticsusceptibilityresultsareavailable
Systemicbacterialcultures(urine,blood,cerebrospinalfluid)isolatenopathogensduringatleast48hoursof
incubation
Resultsofantibioticsusceptibilitytestingshouldbeusedtomakedecisionsaboutwhichoralantibiotictousefor
continuationofsystemictherapy.
AppropriateoralagentsforneonateswithSSTIincludecephalexinandclindamycin,dependinguponthe
susceptibilitiesoftheS.aureusthatisisolated(table3)[6,7].Linezolidmaybeusedwhentheisolateisresistantto
otheragents,butshouldbeusedunderclosesupervisionbyanexpertininfectiousdiseases[3].
Trimethoprimsulfamethoxazoleshouldnotbeusedinneonatesbecauseitmaydisplacebilirubin,increasingtherisk
forbilirubintoxicity.(See"Evaluationofunconjugatedhyperbilirubinemiaintermandlatepreterminfants",sectionon
'Bilirubin/albuminratio'.)
InvasiveinfectionAntimicrobialtherapyforneonateswithinvasivestaphylococcalinfectionsthathaveextended
beyondtheskinandsofttissuesisdiscussedseparately.(See"MethicillinresistantStaphylococcusaureusin
children:Treatmentofinvasiveinfections",sectionon'Treatmentofneonates'.)
RESPONSETOTHERAPY
MonitoringresponseResponsetotherapyisindictedbyclinicalimprovementafter48hours.Inneonateswhoare
admittedtothehospitalforantimicrobialtherapy,wemonitortheSSTIforimprovementorprogression,thepatient'svital
signs,andcultureandsusceptibilityresults(ifobtained).
NeonateswhoaretreatedformethicillinresistantS.aureus(MRSA)intheoutpatientsettingshouldbeinstructedtoseek
medicalcarepromptlyiftheydevelopsystemicsymptomsoriflocalsymptomsworsen[8].Theyshouldbeseenfor
followupwithin48hours.Followupisessentialtoensureclinicalimprovementanddeterminetheneedforadditional
drainageorchangeinantimicrobialtherapy.
FailuretorespondInitiationofsystemictherapy(forneonatesinitiallytreatedwithtopicalantibiotics)orchangein
antimicrobialtherapy(guidedbycultureandsusceptibilityresults,ifavailable)maybewarrantedforpatientswhohavenot
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improvedafter48hoursofobservationorantimicrobialtherapy.
Possibleexplanationsforfailuretorespondinneonatesreceivinganagenttowhichtheirisolateissusceptibleinclude
inadequatedrainage(ifdrainagewasperformed),abscessrecurrence,ordevelopmentofanewabscess.Ultrasonography
mayidentifyresidual,recurrent,ornewabscessesthatrequiredrainage.
Ifculturesremainnegativeandultrasonographydoesnotidentifylesionsthatrequiredrainage,achangeinempirictherapy
maybeindicated(eg,toincludecoverageforMRSAifMRSAwasnotinitiallyincluded).Insuchcases,consultationwith
anexpertininfectiousdiseasesissuggested.
INFORMATIONFORPATIENTSUpToDateofferstwotypesofpatienteducationmaterials,"TheBasics"and"Beyond
theBasics."TheBasicspatienteducationpiecesarewritteninplainlanguage,atthe5thto6thgradereadinglevel,and
theyanswerthefourorfivekeyquestionsapatientmighthaveaboutagivencondition.Thesearticlesarebestfor
patientswhowantageneraloverviewandwhoprefershort,easytoreadmaterials.BeyondtheBasicspatienteducation
piecesarelonger,moresophisticated,andmoredetailed.Thesearticlesarewrittenatthe10thto12thgradereadinglevel
andarebestforpatientswhowantindepthinformationandarecomfortablewithsomemedicaljargon.
Herearethepatienteducationarticlesthatarerelevanttothistopic.Weencourageyoutoprintoremailthesetopicsto
yourpatients.(Youcanalsolocatepatienteducationarticlesonavarietyofsubjectsbysearchingon"patientinfo"andthe
keyword(s)ofinterest.)
Basicstopics(see"Patientinformation:MethicillinresistantStaphylococcusaureus(MRSA)(TheBasics)")
BeyondtheBasicstopic(see"Patientinformation:MethicillinresistantStaphylococcusaureus(MRSA)(Beyondthe
Basics)")
SUMMARYANDRECOMMENDATIONS
ThehistoryandexaminationoftheneonatewithsuspectedStaphylococcusaureusskinandsofttissueinfection
(SSTI)focusonconsiderationofothercausesofSSTIinneonates,particularlythosewithvesicopustularlesions
thatrequireothertypesofantimicrobialtherapythanS.aureusinfections(table1).(See'Historyandexamination'
above.)
WeobtainspecimensforGramstain,culture,andsusceptibilitytestingfromneonateswithpurulent/fluctuantskin
lesions(abscess)ifpurulentmaterialcanbeobtained.Ourapproachtoobtainingotherlaboratorystudiesand
culturesinneonateswithsuspectedS.aureusSSTIdependsuponthetypeofinfectionandassociatedclinical
features.(See'Laboratoryevaluation'above.)
Wesuggestthatlocalizedpustulosis(picture1)infulltermneonateswithoutfeverorothersignsorsymptomsof
infectionbetreatedwithtopicalantibiotictherapyintheoutpatientsetting(Grade2C).Wetypicallyusemupirocin
threetimesdailyfor5to10days.Closeoutpatientfollowupisessential.(See'Localizedpustulosis'above.)
Werecommendhospitaladmissionandparenteralantimicrobialtherapyforlocalpustulosisinpretermorverylow
birthweightneonates(Grade1B).(See'Localizedpustulosis'above.)
Werecommendhospitaladmissionforinfants28dayswithSSTImoreseverethanlocalizedpustulosis(eg,
pustulosisinmultiplesites,cellulitis,abscess,mastitis)andforthosewhoundergoevaluationforseriousbacterial
infection(eg,bacteremia,urinarytractinfection,meningitis,arthritis,osteomyelitis)(Grade1B).(See'SSTIother
thanlocalizedpustulosis'above.)
EmpiricparenteralantibioticsforSSTIinneonatesshouldbebaseduponthelocalsusceptibilitypatternof
communityassociatedS.aureusisolates.InareaswithanincreasedprevalenceofmethicillinresistantS.aureus,
vancomycin,clindamycin,andlinezolidareappropriatealternativesforinfectionlimitedtotheskinandsofttissues
gentamicinmaybeaddedtobroadencoverage(table3).(See'Initialparenteraltherapy'above.)
UseofUpToDateissubjecttotheSubscriptionandLicenseAgreement.
REFERENCES
6/20/2016
1.LiuC,BayerA,CosgroveSE,etal.Clinicalpracticeguidelinesbytheinfectiousdiseasessocietyofamericaforthe
treatmentofmethicillinresistantStaphylococcusaureusinfectionsinadultsandchildren.ClinInfectDis2011
52:e18.
2.AmericanAcademyofPediatrics.Staphylococcalinfections.In:RedBook:2015ReportoftheCommitteeon
InfectiousDiseases,30thed,KimberlinDW,BradyMT,JacksonMA,LongSS(Eds),AmericanAcademyof
Pediatrics,2015.p.715.
3.FortunovRM,HultenKG,HammermanWA,etal.EvaluationandtreatmentofcommunityacquiredStaphylococcus
aureusinfectionsintermandlatepretermpreviouslyhealthyneonates.Pediatrics2007120:937.
4.MillerLG,PerdreauRemingtonF,BayerAS,etal.Clinicalandepidemiologiccharacteristicscannotdistinguish
communityassociatedmethicillinresistantStaphylococcusaureusinfectionfrommethicillinsusceptibleS.aureus
infection:aprospectiveinvestigation.ClinInfectDis200744:471.
5.DayCT,KaplanSL,MasonEO,HultenKG.CommunityassociatedStaphylococcusaureusinfectionsinotherwise
healthyinfantslessthan60daysold.PediatrInfectDisJ201433:98.
6.AutretE,LaugierJ,MarimbuJ,etal.[Comparisonofplasmalevelsofamoxicillinadministeredbyoraland
intravenousroutesinneonatalbacterialcolonization].ArchFrPediatr198845:679.
7.BoothmanR,KerrMM,MarshallMJ,BurlandWL.Absorptionandexcretionofcephalexinbythenewborninfant.
ArchDisChild197348:147.
8.GorwitzRJ.AreviewofcommunityassociatedmethicillinresistantStaphylococcusaureusskinandsofttissue
infections.PediatrInfectDisJ200827:1.
Topic106447Version3.0
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GRAPHICS
Vesiculopustularlesionsinneonatesandinfantsthatrequiretreatment
and/ormonitoring
Condition
Clinicalfeatures
Significance
Infectiousconditions
Congenital
herpes
simplexvirus
(HSV)
Groupedorsinglevesicleson
erythematousbaseincropsonskinand
mucousmembraneslesionsusually
appearbetweenoneandtwoweeksof
agemaybeassociatedwithnonspecific
signsofseriousillness:temperature
instability,respiratorydistress,poor
feeding,lethargy
Requiresantiviraltherapysignificant
morbidityandmortalityifuntreated
Neonatal
varicella
Groupedorsinglevesicleson
erythematousbaseincropsonskinand
Requiresantiviraltherapyassociatedwith
significantmorbidityandmortality
zostervirus
mucousmembranes
Congenital
syphilis
Blisters,erosionsthatfrequentlyinvolve
thepalmsandsolesothermanifestations
includerhinitis,anemia,jaundice,
hepatomegaly
Requiresantibiotictherapylate
manifestationsinuntreatedinfantsmay
includecentralnervoussystem,skeletal,
Staphylococcal
pustulosis
Erythematouspapules,pustules,honey
coloredcrustsofteninareasoftrauma
Requiresantibiotictherapygramstain
andcultureoflesionsshouldbeobtained
maybeassociatedwithsystemic/invasive
infection
Staphylococcal
scaldedskin
syndrome
(SSSS)
Fever,irritability,diffuseblanching
erythema,flaccidblisterspositive
Nikolskysign*
Requiresantibiotictherapycultures
shouldbeobtainedfromanysuspected
focusofinfection(eg,blood,urine,
nasopharynx,umbilicus)
Streptococcal
infections
Maymimicstaphylococcalinfections
Sameasforstaphylococcalpustulosisand
SSSS
Listeria
Pustulesoftheskinandmucus
membranesmaybepresentinearly
onsetdisease(<7daysofage)
Requiresantibiotictherapymaybe
associatedwithsepticemiaand/or
meningitis
Candidiasis
Erythematousmaculesandpapules
evolvingtopustulesandvesicles
Requiresantifungaltherapyhasthe
anddentalabnormalitieshearingloss
andinterstitialkeratitis
potentialtodisseminateviathe
bloodstreaminsusceptiblehosts
Congenitaldisorders
Epidermolysis
bullosa
Blisterdevelopmentwithlittleorno
trauma
Managementinvolvespreventionof
trauma,carefulwoundcare,and
treatmentofinfection
Epidermolytic
hyperkeratosis
Widespreadblisteringanderythemaand
orhyperkeratosisdenudedareasofskin
Increasedsusceptibilitytocutaneous
infection
Aplasiacutis
Erosionspresentatbirththat
Maybeassociatedwithotherdisorders
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congenita
reepitheliazetoformhypertrophicor
atrophicscarinvolvestheepidermisand
dermis
(eg,trisomy13,4p)
Incontinentia
pigmenti
Fourstagesthatmayoccur
simultaneously:linearstreaksof
erythematouspapulesandvesicleswarty
papulesorplaquesinlinearorswirling
patternsswirledhypopigmentedpatches
orstreaks
Majorityofcasesassociatedwith
neurologic,ocular,dental,andstructural
abnormalities
Scabies
Maybeseenininfantsasyoungasthree
tofourweeksofage,butneverpresentat
birthvesicles,pustules,andpapules,rare
burrowsonhands,feet,trunk,genitalia
Requirestreatmentwithscabicideand
measurestopreventspread
Cutaneous
mastocytosis
Bullouseruptionswithhemorrhage
positiveDariersign
Requiressymptomatictherapyand
avoidanceoftriggers
Miscellaneous
*Nikolskysign:separationoftheupperdermisandwrinklingoftheskinwithapplicationofgentlepressure.
Dariersign:urticariaanderythemawithrubbing,scratching,orstroking.
Graphic75417Version3.0
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Clinicalmanifestationsthataresuggestiveofspecificcongenital
infectionsintheneonate
Congenital
toxoplasmosis
Intracranialcalcifications(diffuse)
Hydrocephalus
Chorioretinitis
OtherwiseunexplainedmononuclearCSFpleocytosisorelevatedCSFprotein
Congenitalsyphilis
Skeletalabnormalities(osteochondritisandperiostitis)
Pseudoparalysis
Persistentrhinitis
Maculopapularrash(particularlyonpalmsandsolesorindiaperarea)
Congenitalrubella
Cataracts,congenitalglaucoma,pigmentaryretinopathy
Congenitalheartdisease(mostcommonlypatentductusarteriosusorperipheral
pulmonaryarterystenosis)
Radiolucentbonedisease
Sensorineuralhearingloss
Congenital
cytomegalovirus
Thrombocytopenia
Periventricularintracranialcalcifications
Microcephaly
Hepatosplenomegaly
Sensorineuralhearingloss
Congenitalherpes
simplexvirus
Mucocutaneousvesiclesorscarring
CSFpleocytosis
Thrombocytopenia
Elevatedlivertransaminases
Conjunctivitisorkeratoconjuctivitis
Congenitalvaricella
Cicatricialorvesicularskinlesions
Limbhypoplasia
CSF:cerebrospinalfluid.
Datafrom:
1.MaldonadoYA,NizetV,KleinJO,etal.Currentconceptsofinfectionsofthefetusandnewborninfant.In:
InfectiousDiseasesoftheFetusandNewbornInfant,7thed,RemingtonJS,KleinJO,WilsonCB,etal
(Eds),Saunders,Philadelphia2011.p.2.
2.SanchezPJ,DemmlerHarrisonGJ.Viralinfectionsofthefetusandnewborn.In:FeiginandCherry's
TextbookofPediatricInfectiousDiseases,6thed.FeiginRD,CherryJD,DemmlerHarrisonGJ,KaplanSL
(Eds),Saunders,Philadelphia2009.p.895.
3.StamosJK,RowleyAH.Timelydiagnosisofcongenitalinfections.PediatrClinNorthAm199441:1017.
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Staphylococcalpustulosis
CommunityassociatedStaphylococcusaureuspustulosisinthediaperareaofapreviouslyhealthy
neonate.
CourtesyofSheldonLKaplan,MD
6/20/2016
Dosesforantibioticssuggestedinthetreatmentofsuspected
staphylococcalskinandsofttissueinfectionsinneonates
Parenteral
antibiotics
Infants7daysofage
BW2kg
Infants8to28daysofage
BW>2kg
BW<2kg
BW>2kg
Clindamycin
5mg/kgIV
every12hours
5mg/kgIV
every8hours
5mg/kgIV
every8hours
5mg/kgIVevery6hours
Gentamicin*
5mg/kgIV
every48hours
4mg/kgIV
every24hours
5mg/kgIV
every36hours
4to5mg/kgIVevery24hours
Linezolid
10mg/kgIV
every12hours
10mg/kgIV
every8hours
10mg/kgIV
every8hours
10mg/kgIVevery8hours
Nafcillin
25mg/kgIV
every12hours
25mg/kg
every8hours
25mg/kgIV
every8hours
Oxacillin
25mg/kgIV
every12hours
25mg/kg
every8hours
25mg/kgIV
every8hours
Vancomycin
Dosedaccordingtoserumcreatinineconcentrationasindicatedbelow
Serumcreatinineconcentration(mg/dL)
Oral
antibiotics
<0.7
0.7to0.9
1.0to1.2
1.3to1.6
>1.6
15mg/kgIV
every12hours
20mg/kgIV
every24hours
15mg/kgIV
every24hours
10mg/kgIV
every24hours
15mg/kgIV
every48hours
Infants7daysofage
BW2kg
BW>2kg
Infants8to28daysofage
BW<2kg
BW>2kg
Cephalexin
Oraltherapynotappropriate
6.25to12.5mg/kgorallyevery6hours
Clindamycin
5mg/kgorally
every12hours
5mg/kgorally
every8hours
5mg/kgorallyevery6hours
Linezolid
Oraltherapynotappropriate
10mg/kgorally
every8hours
10mg/kgorallyevery8hours
5mg/kgorally
every8hours
BW:bodyweightIV:intravenously.
*Gentamicinisnecessarytoprovidecoverageforpossiblegramnegativepathogens.Theoptimal,individualized
doseshouldbebasedondeterminationofserumconcentrations.Dosesmaydifferfromthoserecommendedby
thepackageinsert.
Dosingalgorithmforvancomycinbaseduponserumcreatinineconcentrationinneonatesbornatgestational
age>28weeks.Serumcreatinineconcentrationwilltakeapproximately5to7daysafterbirthtoreasonably
reflectneonatalrenalfunction.Cautioususeofcreatininebaseddosingstrategywithfrequentassessmentof
renalfunctionandvancomycinserumconcentrationsarerecommendedinneonates7daysold [1] .A
vancomycindosingmethodbaseduponpostnatalageandweightisprovidedasanalternativetotheserum
creatininebasedmethodlistedaboveandmaybeusefulinsomeclinicalsituations.Thisparticularalgorithmwas
providedinthe2009editionoftheRedBook [2] .
Postnatalage<7days:
<1200g:15mg/kgIVevery24hours

1200to2000g:10to15mg/kgIVevery12or18hours

>2000g:10to15mg/kgIVevery8or12hours
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Postnatalage7days:
<1200g:15mg/kgIVevery24hours

1200to2000g:10to15mg/kgIVevery8or12hours

>2000g:10to15mg/kgIVevery6or8hours
Orallinezolidisreservedforisolatesresistanttootheragentsandshouldbeusedundersupervisionbyan
expertininfectiousdiseases.
References:
1.Nelson'sPediatricAntimicrobialTherapy,21sted,BradleyJS,NelsonJD,CanteyJB,etal(Eds),American
AcademyofPediatrics,ElkGroveVillage,IL2015.p.36.
2.AmericanAcademyofPediatrics.Antibacterialdrugsfornewborninfants:Doseandfrequencyof
administration.In:RedBook:2009ReportoftheCommitteeonInfectiousDiseases,28thed,Pickering
LK(Ed),AmericanAcademyofPediatrics,ElkGroveVillage,IL2009.p.745.
Dataadaptedfrom:AmericanAcademyofPediatrics.Tablesofantibacterialdrugdosages.In:RedBook:2015
ReportoftheCommitteeonInfectiousDiseases,30thed,KimberlinDW,BradyMT,JacksonMA,LongSS(Eds),
AmericanAcademyofPediatrics,ElkGroveVillage,IL2015.p.881.
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6/20/2016
ContributorDisclosures
SheldonLKaplan,MDGrant/Research/ClinicalTrialSupport:Pfizer[S.pneumoniae(PCV13,Linezolid)]Cubist[S.
aureus(Tedizolid)]ForestLab[Osteomyelitis(Ceftaroline)].Consultant/AdvisoryBoards:Pfizer[S.pneumoniae(PCV13,
Linezolid)S.aureus(vaccinedevelopment)]Theravance[S.aureus(Telavancin)].MorvenSEdwards,MD
Grant/Research/ClinicalTrialSupport:PfizerInc.[GroupBStreptococcus].MaryMTorchia,MDNothingtodisclose.
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Suspected Staphylococcus Aureus Skin and Soft Tissue Infections - Evaluation and Management in Neonates PDF

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