BNF for Children 2011-2012

274 5.1.3 Tetracyclines BNFC 2011–20125 Infectionsminute/1.73 m 2 ; usual initial dose, then one-quarternormal dose if estimated glomerular filtration rate lessthan 10 mL/minute/1.73 m 2Pregnancy no information available—manufactureradvises avoidBreast-feeding amount in milk probably too small tobe harmfulSide-effects nausea, vomiting, diarrhoea, abdominalcramps; mouth ulcers, altered taste; jaundice andhepatitis; flushing; hypersensitivity reactions; blooddisorders (including thrombocytopenia and neutropenia);rashes, injection-site reactions; rarely hypotension,seizures, asthenia, confusion, dizziness,headache, halitosis, and breast tenderness; very rarelyantibiotic-associated colitis, gastro-intestinal bleeding,and toxic epidermal necrolysisLicensed use not licensed for use in children under 7daysIndication and doseGram-negative infections including Pseudomonasaeruginosa, Haemophilus influenzae,and Neisseria meningitidis. By intravenous injection over 3–5 minutes orby intravenous infusionNeonate under 7 days 30 mg/kg every 12 hoursNeonate 7–28 days 30 mg/kg every 6–8 hoursChild 1 month–2 years 30 mg/kg every 6–8hoursChild 2–12 years 30 mg/kg every 6–8 hoursincreased to 50 mg/kg every 6–8 hours in severeinfection and cystic fibrosis (max. 2 g every 6hours)Child 12–18 years 1 g every 8 hours or 2 g every12 hours; 2 g every 6–8 hours for severe infections(including systemic Ps. aeruginosa and lunginfections in cystic fibrosis)Administration Displacement value may be significant,consult local guidelines. For intermittent intravenousinfusion, dilute reconstituted solution furtherin Glucose 5% or Sodium chloride 0.9% to a concentrationof less than 20 mg/mL; to be given over20–60 minutesAzactam c (Squibb) AInjection, powder for reconstitution, aztreonam. Netprice 1-g vial = £9.40; 2-g vial = £18.825.1.3 TetracyclinesThe tetracyclines are broad-spectrum antibiotics whosevalue has decreased owing to increasing bacterial resistance.In children over 12 years of age they are useful forinfections caused by chlamydia (trachoma, psittacosis,salpingitis, urethritis, and lymphogranuloma venereum),rickettsia (including Q-fever), brucella (doxycycline witheither streptomycin or rifampicin), and the spirochaete,Borrelia burgdorferi (Lyme disease—see section5.1.1.3). They are also used in respiratory and genitalmycoplasma infections, in acne, in destructive (refractory)periodontal disease, in exacerbations of chronicrespiratory diseases (because of their activity againstHaemophilus influenzae), and for leptospirosis in penicillinhypersensitivity (as an alternative to erythromycin).Microbiologically, there is little to choose between thevarious tetracyclines, the only exception being minocyclinewhich has a broader spectrum; it is activeagainst Neisseria meningitidis and has been used formeningococcal prophylaxis but is no longer recommendedbecause of side-effects including dizzinessand vertigo (see Table 2, section 5.1 for current recommendations).Compared to other tetracyclines, minocyclineis associated with a greater risk of lupus-erythematosus-likesyndrome. Minocycline sometimes causesirreversible pigmentation.For the role of tetracyclines in the management ofmeticillin-resistant Staphylococcus aureus (MRSA)infections, see p. 259.Oral infections In children over 12 years of age,tetracyclines can be effective against oral anaerobesbut the development of resistance (especially by oralstreptococci) has reduced their usefulness for the treatmentof acute oral infections; they may still have a rolein the treatment of destructive (refractory) forms ofperiodontal disease. Doxycycline has a longer durationof action than tetracycline or oxytetracycline and needonly be given once daily; it is reported to be more activeagainst anaerobes than some other tetracyclines.For the use of doxycycline in the treatment of recurrentaphthous ulceration, oral herpes, or as an adjunct togingival scaling and root planing for periodontitis, seesection 12.3.1 and section 12.3.2.Cautions Tetracyclines may increase muscle weaknessin patients with myasthenia gravis, and exacerbate systemiclupus erythematosus. Antacids, and aluminium,calcium, iron, magnesium and zinc salts decrease theabsorption of tetracyclines; milk also reduces theabsorption of demeclocycline, oxytetracycline, andtetracycline. Other interactions: Appendix 1 (tetracyclines).Contra-indications Deposition of tetracyclines ingrowing bone and teeth (by binding to calcium) causesstaining and occasionally dental hypoplasia, and theyshould not be given to children under 12 years, or topregnant or breast-feeding women. However, doxycyclinemay be used in children for treatment and postexposureprophylaxis of anthrax when an alternativeantibacterial cannot be given [unlicensed indication].Tetracyclines should not be given to children withacute porphyria (section 9.8.2).Hepatic impairment Tetracyclines should be avoidedor used with caution in children with hepatic impairment.Tetracyclines should also be used with caution inthose receiving potentially hepatotoxic drugs.Renal impairment With the exception of doxycyclineand minocycline, the tetracyclines may exacerbaterenal failure and should not be given to children withrenal impairment.Pregnancy Tetracyclines should not be given topregnant women; effects on skeletal developmenthave been documented in the first trimester in animalstudies. Administration during the second or third trimestermay cause discoloration of the child’s teeth, andmaternal hepatotoxicity has been reported with largeparenteral doses.