Suggested empiric intravenous antibiotic regimens for treatment of bacterial tracheitis in children

Antimicrobial regimens
Our preferred regimen	Alternative options
Vancomycin 15 mg/kg per dose every 6 to 8 hours (maximum daily dose: 4 g)^¶ Plus* 1 of the following: Ceftriaxone 50 mg/kg per dose every 12 to 24 hours (maximum daily dose: 2 g), or Cefotaxime (if available) 150 to 200 mg/kg per day in 4 divided doses (maximum dose 2 g)^¶, or Ampicillin-sulbactam 150 to 200 mg/kg (of ampicillin component) per day in 4 divided doses (maximum daily dose: 8 g)^¶	Linezolid can be substituted for vancomycin Linezolid dosing:^Δ <12 years: 10 mg/kg per dose every 8 hours (maximum dose 600 mg) ≥12 years: 600 mg per dose every 12 hours Monotherapy with ceftaroline is a reasonable alternative to combination therapy Ceftaroline dosing:^Δ 15 mg/kg per dose every 8 hours (maximum dose 600 mg)^¶ Clindamycin can be substituted for vancomycin for nonsevere/non-life-threating infections in settings where the prevalence of clindamycin resistance among Staphylococcus aureus isolates is low^◊ Clindamycin dosing: 40 mg/kg per day in 3 divided doses (maximum daily dose: 2.7 g)
For patients with potential severe hypersensitivity to beta-lactam antibiotics (eg, penicillin, cephalosporin): Levofloxacin or ciprofloxacin can be substituted for the cephalosporin/ampicillin-sulbactam component of the regimen Levofloxacin dosing: 6 months to 5 years: 10 mg/kg per dose every 12 hours (maximum daily dose: 500 mg)^¶ ≥5 years: 10 mg/kg per dose once daily (maximum daily dose: 500 mg)^Δ Ciprofloxacin dosing: 20 to 30 mg/kg per day in 2 divided doses (maximum daily dose: 800 mg)^¶
For patients with nonanaphylactic hypersensitivity to penicillin and cephalosporin: Aztreonam or meropenem can be substituted for the cephalosporin/ampicillin-sulbactam component of the regimen Aztreonam dosing: 90 to 120 mg/kg per day in 3 to 4 divided doses (maximum daily dose: 8 g)^¶ Meropenem dosing: 20 mg/kg per dose every 8 hours (maximum daily dose 6 g)^¶

This table summarizes our recommendations for empiric antibiotic therapy for children with bacterial tracheitis. Final therapy decisions should be based upon results of cultures and susceptibility testing. Consultation with an expert in infectious diseases may be warranted for guidance regarding choice and duration of antimicrobial therapy.

* For life-threatening infections, vancomycin should given every 6 hours. Trough levels of 15 to 20 mcg/mL are suggested for severe infections. For further details, refer to separate UpToDate content on treatment of S. aureus infections in children.
¶ Dose adjustment is necessary for patients with renal impairment. Refer to drug information topics for details.
Δ Experience with these agents in children is limited. Consultation with an infectious diseases specialist is suggested.
◊ Information regarding local susceptibility patterns can be obtained from local public health officials or hospital laboratories. The threshold prevalence of clindamycin-resistant S. aureus for choosing vancomycin varies from center to center, usually ranging from 10 to 25%, in an effort to balance the benefit of definitive therapy for the patient with the risk of increasing vancomycin resistance in the community. For further details, refer to separate UpToDate content on treatment of S. aureus infections in children.

References:

American Academy of Pediatrics. Staphylococcus aureus. In: Red Book: 2018 Report of the Committee on Infectious Diseases, 31^st ed, Kimberlin DW, Brady MT, Jackson MA, Long SS (Eds), American Academy of Pediatrics, Itasca, IL 2018. p.733.
American Academy of Pediatrics. Tables of antibacterial drug dosages. In: Red Book: 2018 Report of the Committee on Infectious Diseases, 31^st ed, Kimberlin DW, Brady MT, Jackson MA, Long SS (Eds), American Academy of Pediatrics, Itasca, IL 2018. p.914.

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Suggested empiric intravenous antibiotic regimens for treatment of bacterial tracheitis in children