BNF for Children 2011-2012

BNFC 2011–2012 5.1.13 Urinary-tract infections 299Intravenous infusion, ciprofloxacin (as lactate)2 mg/mL, in sodium chloride 0.9%, net price 50-mLbottle = £7.61, 100-mL bottle = £15.02, 200-mL bottle= £22.85Electrolytes Na + 15.4 mmol/100-mL bottleNALIDIXIC ACIDCautions see notes above; avoid in acute porphyria(section 9.8.2); false positive urinary glucose (if testedfor reducing substances); monitor blood counts, renaland liver function if treatment exceeds 2 weeks;interactions: Appendix 1 (quinolones)Contra-indications see notes aboveHepatic impairment manufacturer advises caution inliver diseaseRenal impairment use with caution; avoid if estimatedglomerular filtration rate less than 20 mL/minute/1.73 m 2Pregnancy see notes aboveBreast-feeding risk to infant very small but one caseof haemolytic anaemia reportedSide-effects see notes above; also reported toxicpsychosis, increased intracranial pressure, cranialnerve palsy, peripheral neuropathy, metabolic acidosisLicensed use not licensed for use in children under 3months of ageIndication and doseUrinary tract infection resistant to other antibiotics. By mouthChild 3 months–12 years 12.5 mg/kg 4 timesdaily for 7 days, reduced to 7.5 mg/kg 4 times dailyin prolonged therapy or 15 mg/kg twice daily forprophylaxisChild 12–18 years 900 mg 4 times daily for 7days, reduced in chronic infections to 600 mg 4times dailyNalidixic acid (Rosemont) ASuspension, pink, nalidixic acid 300 mg/5 mL, netprice 150 mL (raspberry- and strawberry-flavoured) =£12.50. Label: 9, 11Excipients include sucrose 450 mg/5 mL5.1.13 Urinary-tract infectionsUrinary-tract infection is more common in adolescentgirls than in boys; when it occurs in adolescent boysthere is frequently an underlying abnormality of therenal tract. Recurrent episodes of infection are an indicationfor radiological investigation especially in childrenin whom untreated pyelonephritis may lead topermanent kidney damage.Escherichia coli is the most common cause of urinarytractinfection; Staphylococcus saprophyticus is alsocommon in sexually active young women. Less commoncauses include Proteus and Klebsiella spp. Pseudomonasaeruginosa infections usually occur in the hospitalsetting and may be associated with functional oranatomical abnormalities of the renal tract. Staphylococcusepidermidis and Enterococcus faecalis infectionmay complicate catheterisation or instrumentation.A specimen of urine should be collected for cultureand sensitivity testing before starting antibacterialtherapy;. in children under 3 years of age;. in children with suspected upper urinary-tractinfection, complicated infection, or recurrentinfection;. if resistant organisms are suspected;. if urine dipstick testing gives a single positiveresult for leucocyte esterase or nitrite;. if clinical symptoms are not consistent withresults of dipstick testing;. in pregnant women.Treatment should not be delayed while waiting forresults. The antibacterial chosen should reflect currentlocal bacterial sensitivity to antibacterials.Urinary-tract infections in children require prompt antibacterialtreatment to minimise the risk of renal scarring.Uncomplicated ‘lower’ urinary-tract infections inchildren over 3 months of age can be treated withtrimethoprim, nitrofurantoin, a first generation cephalosporin,or amoxicillin for 3 days; children should bereassessed if they continue to be unwell 24–48 hoursafter the initial assessment.Acute pyelonephritis in children over 3 months of agecan be treated with a first generation cephalosporin orco-amoxiclav for 7–10 days. If the patient is severely ill,then the infection is best treated initially by intravenousinjection of a broad-spectrum antibacterial such as cefotaximeor co-amoxiclav; gentamicin is an alternative.Children under 3 months of age should be transferred tohospital and treated initially with intravenous antibacterialssuch as ampicillin with gentamicin, or cefotaximealone, until the infection responds; full doses of oralantibacterials are then given for a further period.Resistant infections Widespread bacterial resistanceto ampicillin, amoxicillin, and trimethoprim has beenreported. Alternatives for resistant organisms includeco-amoxiclav (amoxicillin with clavulanic acid), an oralcephalosporin, pivmecillinam, or a quinolone.Antibacterial prophylaxis Recurrent episodes ofinfection are an indication for imaging tests. Antibacterialprophylaxis with low doses of trimethoprimor nitrofurantoin may be considered for children withrecurrent infection, significant urinary-tract anomalies,or significant kidney damage. Nitrofurantoin is contraindicatedin children under 3 months of age because ofthe theoretical possibility of haemolytic anaemia.Pregnancy Urinary-tract infection in pregnancy maybe asymptomatic and requires prompt treatment toprevent progression to acute pyelonephritis. Penicillinsand cephalosporins are suitable for treating urinarytractinfection during pregnancy. Nitrofurantoin mayalso be used but it should be avoided at term. Sulfonamides,quinolones, and tetracyclines should be avoidedduring pregnancy; trimethoprim should also preferablybe avoided particularly in the first trimester.Renal impairment In renal failure antibacterialsnormally excreted by the kidney accumulate with resultanttoxicity unless the dose is reduced. This appliesespecially to the aminoglycosides which should be used5 Infections