BNF for Children 2011-2012

244 5.1 Antibacterial drugs BNFC 2011–2012enteral administration is also appropriate when theoral route cannot be used (e.g. because of vomiting)or if absorption is inadequate (e.g. in neonates andyoung children). Whenever possible painful intramuscularinjections should be avoided in children;. Duration of therapy depends on the nature of theinfection and the response to treatment. Coursesshould not be unduly prolonged because theyencourage resistance, they may lead to side-effectsand they are costly. However, in certain infectionssuch as tuberculosis or osteomyelitis it may benecessary to treat for prolonged periods.changed, preferably on the basis of bacteriologicalinvestigation. Failure to respond may also suggest anincorrect diagnosis, lack of essential additional measures(such as drainage), poor host resistance, or poorpatient compliance.Combination of a penicillin (or erythromycin) withmetronidazole may sometimes be helpful for the treatmentof severe or resistant oral infections.See also Penicillins (section 5.1.1), Cephalosporins(section 5.1.2.1), Tetracyclines (section 5.1.3), Macrolides(section 5.1.5), Clindamycin (section 5.1.6),Metronidazole (section 5.1.11), Fusidic acid (section13.10.1.2).5 InfectionsOral bacterial infections Antibacterial drugs shouldonly be prescribed for the treatment of oral infections onthe basis of defined need. They may be used in conjunctionwith (but not as an alternative to) other appropriatemeasures, such as providing drainage or extractinga tooth.The ‘blind’ prescribing of an antibacterial for unexplainedpyrexia, cervical lymphadenopathy, or facialswelling can lead to difficulty in establishing the diagnosis.A sample should always be taken for bacteriologyin the case of severe oral infection.Oral infections which may require antibacterial treatmentinclude acute periapical or periodontal abscess,cellulitis, acutely created oral-antral communication(and acute sinusitis), severe pericoronitis, localisedosteitis, acute necrotising ulcerative gingivitis, anddestructive forms of chronic periodontal disease. Mostof these infections are readily resolved by the earlyestablishment of drainage and removal of the cause(typically an infected necrotic pulp). Antibacterialsmay be required if treatment has to be delayed, inimmunocompromised patients, or in those with conditionssuch as diabetes. Certain rarer infections includingbacterial sialadenitis, osteomyelitis, actinomycosis, andinfections involving fascial spaces such as Ludwig’sangina, require antibiotics and specialist hospital care.Antibacterial drugs may also be useful after dentalsurgery in some cases of spreading infection. Infectionmay spread to involve local lymph nodes, to fascialspaces (where it can cause airway obstruction), or intothe bloodstream (where it can lead to cavernous sinusthrombosis and other serious complications). Extensionof an infection can also lead to maxillary sinusitis;osteomyelitis is a complication, which usually ariseswhen host resistance is reduced.If the oral infection fails to respond to antibacterialtreatment within 48 hours the antibacterial should beSuperinfection In general, broad-spectrum antibacterialdrugs such as the cephalosporins are morelikely to be associated with adverse reactions related tothe selection of resistant organisms e.g. fungal infectionsor antibiotic-associated colitis (pseudomembranouscolitis); other problems associated with superinfectioninclude vaginitis and pruritus ani.Therapy Suggested treatment is shown in Table 1.When the pathogen has been isolated treatment may bechanged to a more appropriate antibacterial if necessary.If no bacterium is cultured the antibacterial can becontinued or stopped on clinical grounds. Infections forwhich prophylaxis is useful are listed in table 2.Switching from parenteral to oral treatment Theongoing parenteral administration of an antibacterialshould be reviewed regularly. In older children it maybe possible to switch to an oral antibacterial; in neonatesand infants this should be done more cautiouslybecause of the relatively high incidence of bacteraemiaand the possibility of variable oral absorption.Prophylaxis Infections for which antibacterial prophylaxisis useful are listed in Table 2. In most situations,only a short course of prophylactic antibacterial isneeded. Longer-term antibacterial prophylaxis is appropriatein specific indications such as vesico-uretericrefluxTable 1. Summary of antibacterial therapyIf treating a patient suspected of suffering from a notifiable disease, the consultant in communicable diseasecontrol should be informed (see p. 243)Gastro-intestinal systemGastro-enteritisFrequently self-limiting and may not be bacterial.Antibacterial not usually indicated