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Complete Summary
GUIDELINE TITLE
BIBLIOGRAPHIC SOURCE(S)
Singapore Ministry of Health. Use of antibiotics in paediatric care. Singapore: Singapore Ministry of Health; 2002 Mar. 109 p. [193 references] GUIDELINE STATUS
This is the current release of the guideline. COMPLETE SUMMARY CONTENT
SCOPE METHODOLOGY - including Rating Scheme and Cost Analysis RECOMMENDATIONS EVIDENCE SUPPORTING THE RECOMMENDATIONS BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS CONTRAINDICATIONS QUALIFYING STATEMENTS IMPLEMENTATION OF THE GUIDELINE INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES IDENTIFYING INFORMATION AND AVAILABILITY DISEASE/CONDITION(S)
• Upper respiratory tract infections (rhinitis, pharyngitis and tonsillitis, acute sinusitis, acute otitis externa, acute otitis media, recurrent otitis media and otitis media with effusion) • Lower respiratory tract infections (bronchiolitis, acute laryngotracheobronchitis, bronchitis and pneumonia) • Upper and lower gastrointestinal disease • Upper urinary tract infection (pyelonephritis) • Lower urinary tract infection (cystitis) • Bacterial skin infections (impetigo, ecthyma, folliculitis, furunculosis and carbuncles, erysipelas, cellulitis, necrotising fasciitis, staphylococcal scalded skin syndrome, blistering dactylitis, toxic shock syndrome [TSS], methicillin-resistant Staphylococcus aureus [MRSA] infection and perianal streptococcal dermatitis) GUIDELINE CATEGORY
CLINICAL SPECIALTY
Family Practice Infectious Diseases Nursing Pediatrics Pharmacology INTENDED USERS
Advanced Practice Nurses Clinical Laboratory Personnel Hospitals Nurses Pharmacists Physician Assistants Physicians GUIDELINE OBJECTIVE(S)
To provide recommendations for practitioners in the rational use of antibiotics when dealing with childhood infections TARGET POPULATION
Children in Singapore who require antibiotic therapy. High-risk patients such as those who are immunocompromised, have chronic debilitating disease or serious cardiopulmonary conditions are not covered in these guidelines. INTERVENTIONS AND PRACTICES CONSIDERED
Use of antibiotics in paediatric care, including choice of antibiotics for use with the appropriate indications, correct dosages, and duration needed to achieve optimum results. The following antibiotics are considered: 1. Amikacin 2. Amoxycillin 3. Amoxycillin/clavulanate 4. Ampicillin 5. Ampicillin/sulbactam 6. Azithromycin 7. Cefadroxil 8. Cefoxitin 9. Cephalexin 10. Ceftriaxone 11. Cefotaxime 12. Cefuroxime 13. Clarithromycin 14. Clavulanate 15. Clindamycin 16. Cloxacillin 17. Cotrimoxazole (trimethoprim and sulphamethoxazole) 18. Doxycycline 19. Erythromycin 20. Fusidic acid 21. Gentamicin 22. Imipenem 23. Macrolides 24. Metronidazole 25. Minocycline 26. Mupirocin 27. Nitrofurantoin 28. Omeprazole 29. Paromomycin 30. Penicillins G and V 31. Vancomycin MAJOR OUTCOMES CONSIDERED
• Antimicrobial sensitivity resistance METHODOLOGY
METHODS USED TO COLLECT/SELECT EVIDENCE
DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE
NUMBER OF SOURCE DOCUMENTS
METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE
EVIDENCE

Weighting According to a Rating Scheme (Scheme Given) RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE
Levels of Evidence
Ia Evidence obtained from meta-analysis of randomised controlled trials.
Ib Evidence obtained from at least one randomised controlled trial.
IIa Evidence obtained from at least one well-designed controlled study without
randomisation.
IIb Evidence obtained from at least one other type of well-designed quasi-
experimental study.
III Evidence obtained from well-designed non-experimental descriptive studies,
such as comparative studies, correlation studies and case studies.
IV Evidence obtained from expert committee reports or opinions and/or clinical
experiences of respected authorities.
METHODS USED TO ANALYZE THE EVIDENCE
Review of Published Meta-Analyses Systematic Review DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE
METHODS USED TO FORMULATE THE RECOMMENDATIONS
RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS
Grades of Recommendation
Grade A (evidence levels Ia, Ib) Requires at least one randomised controlled trial
as part of the body of literature of overall good quality and consistency addressing
the specific recommendation.
Grade B (evidence levels IIa, IIb, III) Requires availability of well conducted
clinical studies but no randomised clinical trials on the topic of recommendation.
Grade C (evidence level IV) Requires evidence obtained from expert committee
reports or opinions and/or clinical experiences of respected authorities. Indicates
absence of directly applicable clinical studies of good quality.
GPP (good practice points) Recommended best practice based on the clinical
experience of the guideline development group.
COST ANALYSIS
A formal cost analysis was not performed and published cost analyses were not reviewed. METHOD OF GUIDELINE VALIDATION
DESCRIPTION OF METHOD OF GUIDELINE VALIDATION
The drafts of the guidelines were distributed to the following institutions/organisations for vetting and feedback: Chapter of Paediatricians, Academy of Medicine; Singapore Paediatric Society; College of Family Physicians; Departments of Paediatrics and Neonatology at KK Women´s and Children´s Hospital and National University Hospital; Department of Neonatology, Singapore General Hospital; National Skin Centre; Family Health Service, Ministry of Health; East Shore Hospital; Gleneagles Medical Centre Ltd; Mount Alvernia Hospital; Mount Elizabeth Hospital Ltd; Thomson Medical Centre; Raffles Medical Group Ltd; Singapore Baby and Child Clinic; Deputy Director (Clinical Services), National Neuroscience Institute; and Head, Department of Pharmacology, National University of Singapore. A panel discussion was convened to discuss the drafts and the feedback received from the various groups of doctors. Amendments were made and finally editing was carried out. RECOMMENDATIONS
MAJOR RECOMMENDATIONS
Each recommendation is rated based on the levels of the evidence and the grades of recommendation. Definitions of the grades of the recommendations (A, B, C, Good Practice Points) and levels of the evidence (Level I - Level IV) are presented at the end of the Major Recommendations field. Respiratory Tract Infections
Upper Respiratory Tract Infections
A - Upper respiratory tract infections are usually viral in origin and often do not
require antibiotics. (Grade A, Level Ia)
Acute Rhinitis
A - Antibiotics are not indicated for acute rhinitis since the majority are viral in
origin (Fahey & Stocks, 1998; Gadomski, 1993; Kaiser et al., 1996). (Grade A,
Level Ia
)
Pharyngitis and tonsillitis
The following antibiotics should only be given to an older child with possible Streptococcus group A infection who looks unwell, has prolonged fever, sore throat, exudates over the tonsils and enlarged, tender cervical lymph nodes: A - Penicillin V (50mg/kg/day divided 6hrly for 10 days) (Bisno et al., 1997;
Schwartz et al., 1998) (Grade A, Level Ia)
A - Amoxycillin (50mg/kg/day divided 8hrly for 6 days) (Cohen et al., 1996;
Peyramond et al., 1996; Pichichero & Cohen, 1997) or (Grade A, Level Ia)
A - Erythromycin (50mg/kg/day divided 6-8hrly for 10 days for patient with
penicillin allergy) (Bisno et al., 1997; Schwartz et al., 1998) (Grade A, Level Ib)
Acute sinusitis
A - Acute sinusitis is commonly bacterial in origin and requires amoxycillin or
cotrimoxazole (contra-indicated in children with glucose-6-phosphate-
dehydrogenase [G6PD] deficiency) (Trimethoprim [TMP] 8mg/kg/day plus
Sulphamethoxazole [SMX] 40mg/kg/day divided 12hrly) for 7-10 days if there is a
history of penicillin allergy. (Grade A, Level Ia)
C - If there is no response after 72 hours, it is advisable to switch to
amoxycillin/clavulanate (amoxycillin 50mg/kg/day + clavulanate 7mg/kg/day
divided 12hrly) or ampicillin/sulbactam (25- 50mg/kg/day divided 12hrly).
(Grade C, Level IV)
GPP - Referral to an ear, nose, and throat (ENT) specialist is recommended in the
presence of complications or when symptoms persist beyond three weeks (Low et
al., 1997).
Acute otitis externa
C - Acute otitis externa is commonly caused by Staphylococcus aureus. Topical
antimicrobial eardrops (Klein & Bluestone, 1998; Ruddy & Bickerton, 1992) (e.g.
polymyxin, framycetin) are sufficient for mild infections. Severe infections can be
treated with oral cloxacillin (Bojrab, Bruderly, & Abdulrazzak, 1996; Klein &
Bluestone, 1998) for 7 days or erythromycin (if the patient is allergic to penicillin).
(Grade C, Level IV)
Acute otitis media
A - Acute otitis media can be treated with amoxycillin for 7 days (Dowell et al.,
1999; Kozyrskyj, 1998; Rosenfeld et al., 1994). (Grade A, Level Ia)
If there is no response after treatment for 72 hours, high dosages of the following are recommended: • A - amoxycillin/clavulanate (Bottenfield et al., 1998; Dowell et al., 1999)
(Grade A, Level Ia)
A - cefuroxime (15-30mg/kg/day divided 12hrly) (Dowell et al., 1999;
Kozyrskyj, 1998) (Grade A, Level Ib)
A - In the presence of penicillin allergy, treat with erythromycin or cotrimoxazole
(contra-indicated in children with G6PD deficiency) (Rosenfeld et al., 1994).
(Grade A, Level Ia)
Recurrent otitis media and otitis media with effusion
A - A child with recurrent otitis media and otitis media with effusion should be
referred to an ENT surgeon. (Grade A, Level Ia)
Lower Respiratory Tract Infections
Acute bronchiolitis
A - Acute bronchiolitis is caused by respiratory viruses (mainly Respiratory
Syncytial Virus) and antibiotics are not indicated (Friis et al., 1984; Makela,
Ruuskanen & Ogra, 1994). Antibiotics can be considered in the presence of
bacterial superinfection. (Grade A, Level Ib)
Acute laryngotracheobronchitis
C - Respiratory viruses, mainly parainfluenza virus, are responsible for acute
laryngotracheobronchitis. Antibiotics are not indicated (Dawson et al., 1992;
Skolnik, 1989). (Grade C, Level IV)
Acute bronchitis
A - Acute bronchitis is mainly viral in origin (Yun et al., 1995) and antibiotics are
not routinely recommended (Orr et al., 1993; Smucny et al., 1998). (Grade A,
Level Ia
)
B - A macrolide is recommended in an older child when mycoplasma infection is
suspected. (Grade B, Level III)
Pneumonia
C - Referral to hospital is recommended for newborns with pneumonia. (Grade C,
Level IV
)
C - In children less than 2 years old, the majority of pneumonias are viral in
aetiology and antibiotic therapy is not warranted. Bacterial infection is suggested
by toxic appearance, prolonged fever, cough and breathlessness persisting for
more than 1 week, crepitations or decreased breath sounds on auscultation,
leukocytosis and lobar consolidation. Amoxycillin (Bartlett & Mundy, 1995;
Pallares et al., 1995; Pallares et al., 1998) or erythromycin (Barry et al., 1994;
Chenoweth & Lynch, 1997; Doern, 1995; Washington, 1996) is the drug of choice.
If drug resistant Streptococcus pneumoniae is suspected, high dose amoxycillin is
indicated. Second line drugs include amoxycillin/clavulanate or
ampicillin/sulbactum (Barry et al., 1994; Chenoweth & Lynch, 1997; Doern, 1995;
Scriver, Walmsley, & Kau, 1994; Thornsberry et al., 1997; Washington, 1996).
(Grade C, Level IV)
C - For children older than 2 years old, amoxycillin (high dose if resistant
Streptococcus pneumoniae is suspected) is recommended (Bartlett & Mundy,
1995; Pallares et al., 1995; Pallares et al., 1998). Second line drugs include
amoxycillin/clavulanate or ampicillin/sulbactum (Barry et al., 1994; Chenoweth &
Lynch, 1997; Doern, 1995; Scriver, Walmsley, & Kau, 1994; Thornsberry et al.,
1997; Washington, 1996). A macrolide is recommended if mycoplasma infection is
suspected or penicillin allergy is present (Bartlett & Mundy, 1995). (Grade C,
Level IV
)
Gastrointestinal Diseases
GPP - The mainstay of management of gastroenteritis is the prevention and
correction of dehydration and electrolyte imbalance.
Viral diarrhoea
GPP - Viral diarrhoea should not be treated with antibiotics.
Nontyphoidal salmonella infection
A - Nontyphoidal salmonella infection should not be treated routinely with
antibiotics. (Grade A, Level Ia)
C - Antibiotics are required for patients with evidence of extraintestinal spread
such as septicaemia, in the very young (< 3 month old) and in the
immunocompromised child. (Grade C, Level IV)
C - Cotrimoxazole (TMP, 10mg/kg/day plus SMX, 50mg/kg/day divided 12hrly;
contra-indicated in children with G6PD deficiency), ampicillin (200mg/kg/day
divided 6hrly) or a third generation cephalosporin (e.g. ceftriaxone 75-
100mg/kg/day 24hrly) can be given for up to 14 days. (Grade C, Level IV)
Escherichia coli diarrhoea
C - When the disease is severe, antibiotics such as cotrimoxazole (contra-
indicated in children with G6PD deficiency) or ampicillin for 5 to 7 days may be
required. (Grade C, Level IV)
Shigellosis
B - Shigellosis responds to antibiotics (Chang et al., 1977; Haltalin et al., 1967).
Cotrimoxazole (contra-indicated in children with G6PD deficiency), ampicillin or a
third generation cephalosporin can be given for up to 5 days. (Grade B, Level
IIa
)
C - Antibiotics decrease the duration of diarrhoea, excretion of organisms in the
stool and total amount of fluid loss. Doxycycline (6mg/kg as a single dose) is the
drug of choice for children above 8 years old (Cohen & Laney, 1999; World Health
Organization, 1991). (Grade C, Level IV)
Campylobacter gastroenteritis
C - Erythromycin (50mg/kg/day divided 6hrly) for 7 to 10 days (Cohen & Laney,
1999) can be used for patients with severe ongoing illness or if risk factors are
present. (Grade C, Level IV)
Yersinia enterocolitis
C - Diarrhoea is self-limiting except for the immunocompromised child who may
respond to a third generation cephalosporin in combination with gentamicin
(Fasano, 2000) (5mg/kg/day in divided doses). (Grade C, Level IV)
Amoebiasis
C - Antibiotics are employed in the eradication of the amoeba. Treatment consists
of metronidazole (35-50mg/kg/day divided 8hrly orally for 10 days) or tinidazole
(50-60mg/kg/day as a single dose daily for 3 days) followed by paromomycin (25-
35mg/kg/day divided 8hrly for 7 days) (American Academy of Pediatrics, 1997;
Singh-Naz & Rodriquez, 1995). (Grade C, Level IV)
Giardiasis
A - Metronidazole (22.5mg/kg/day divided 8hrly orally for 7 days) is effective
(American Academy of Pediatrics, 1997; Hill, 1993; Singh-Naz & Rodriquez, 1995;
Zaat, Mank, & Assendelft, 2000). (Grade A, Level Ia)
Cryptosporidium
C - Diarrhoeal illness is self-limiting except for the immunocompromised child.
Those who are seriously ill may respond to paromomycin (American Academy of
Pediatrics, 1997) in combination with azithromycin (Flynn, 2000). (Grade C,
Level IV
)
Helicobacter pylori
B - Eradication of Helicobacter pylori is important in the prevention of recurrence
of Helicobacter pylori-associated peptic ulcer disease. Treatment consists of
omeprazole, clarithromycin and metronidazole for 1 to 2 weeks (Casswall et al.,
1998; Dohil, Israel, & Hassell, 1997; Walsh et al., 1997). (Grade B, Level III)
Acute Bacterial Meningitis
GPP - Blood culture, cerebrospinal fluid (CSF) microscopy and culture should be
carried out when a clinical diagnosis of meningitis is made. Empirical antibiotics
should be started with necessary alteration when the culture and sensitivities
become available.
B - For infants below 1 month of age, the likely organisms are Group B
Streptococcus, E. coli or Listeria monocytogenes. Ampicillin (200-300mg/kg/day
divided 4-8hrly) + gentamicin or ampicillin + cefotaxime** (100-200mg/kg/day
divided 6-12hrly) / ceftriaxone** 50-75mg/kg/day 12-24hrly) are the drugs of
choice. (Refer to the original guideline document for additional information.)
(Grade B, Level III)
B - For infants between 1 and 3 months of age, the likely organisms include
Group B Streptococcus, Escherichia coli, Listeria monocytogenes, Streptococcus
pneumoniae
, Neisseria meningitidis and Haemophilus influenzae type b. Ampicillin
plus ceftriaxone/cefotaxime are the drugs of choice. (Grade B, Level III)
A - For infants above 3 months of age, the likely organisms include Streptococcus
pneumoniae
, Neisseria meningitidis and Haemophilus influenzae type b. The drug
of choice is ceftriaxone or cefotaxime. (Grade A, Level Ib)
C - Vancomycin (60mg/kg/day divided 6hrly) is added when antibiotic resistant
Streptococcus pneumoniae is suspected. (Refer to the original guideline document
for additional information.) (Grade C, Level IV)
A - Chemoprophylaxis should be considered in contacts of patients with
Haemophilus influenzae type b or meningococcal meningitis. (Refer to the original
guideline document for additional information.) (Grade A, Level Ib)
B - If antibiotics other than ceftriaxone or cefotaxime were used to treat
Haemophilus influenzae type b or meningococcal meningitis, rifampicin is given at
the end of therapy to clear nasopharyngeal carriage. (Refer to the original
guideline document for additional information.) (Grade B, Level IIb)
Urinary Tract Infections
GPP - Paediatric patient with a clinical diagnosis of urinary tract infection should
have a urine sample obtained for culture and sensitivity before commencement of
antibiotics.
Lower Urinary Tract Infection/Acute Cystitis
B - Patients with dysuria, urinary frequency, suprapubic pain, pyuria or balanitis
can be managed on an outpatient basis. (Grade B, Level III)
All neonates, young infants and febrile children are excluded from this diagnosis. Antibiotics in order of preference are: A - Cotrimoxazole (Dagan, Einhorn, & Lang, 1992; Grubbs et al., 1992; Howard &
Howard, 1978): TMP 8mg plus SMX 40mg/kg/day divided 12hrly (contra-indicated
in children with G6PD deficiency) (Grade A, Level Ib)
A - Nitrofurantoin (Lohr et al., 1981): 5-7mg/kg/day divided 6hrly (contra-
indicated in children with G6PD deficiency) (Grade A, Level Ib)
A - Cephalosporins (McCracken et al., 1981) such as cephalexin, 50mg/kg/day
divided 8hrly, especially in patients with G6PD deficiency (Grade A, Level Ib)
B - Trimethoprim (Rajkumar et al., 1988-89), especially in patients with G6PD
deficiency: 6-8mg/kg/day divided 12hrly (Grade B, Level IIa)
A - < 7 years old: 7-10 days (Grade A, Level Ia)
A - > 12 years old: 3 days of TMZ+SMX can be considered (Grade A, Level Ia)
C - 7-12 years old: 7-10 days (Grade C, Level IV)
Upper Urinary Tract Infection/Acute Pyelonephritis
Antibiotics in order of preference: C - For a baby younger than 28 days old: Ampicillin plus gentamicin (Grade C,
Level IV
)
C - For an infant older than 28 days old: Gentamicin (Grade C, Level IV)
B - Ceftriaxone or cefotaxime:
For neonate with hyperbilirubinaemia, cefotaxime is preferred. (Grade B, Level
III
)
GPP - Antibiotic regimes should be given for a total of 10 to 14 days.
GPP - Neonate <28 days old: intravenous therapy until no fever for 48-72 hours
then convert to appropriate oral therapy based on culture/sensitivity.
GPP - Infant >28 days old: parenteral antibiotic therapy until clinical response
has been demonstrated for 24 hours, then convert to appropriate oral therapy.
Bacterial Skin Infections
Impetigo
B - The majority of impetigo cases are caused by Staphylococcus aureus, some by
a combination of both Staphylococcus aureus and Streptococcus pyogenes and
few by Streptococcus pyogenes. The drug of choice is oral cloxacillin (30-
50mg/kg/day divided 6hrly) or oral cephalexin (30-50mg/kg/day divided 8hrly)
(Wortman, 1993). For children with penicillin allergy, alternatives include
erythromycin (30-50mg/kg/day divided 6hrly) (Barton, Friedman, & Portilla,
1988; Tan, Tay, & Goh, 1998) or cotrimoxazole (TMP 8mg + SMX 40mg/kg/day
divided 12hrly (Tan, Tay, & Goh, 1998); contra-indicated in children with G6PD
deficiency). Duration of treatment ranges from 5 to 10 days. (Grade B, Level
III
)
B - Ecthyma is caused by Streptococcus pyogenes, Staphylococcus aureus or a
combination of the two organisms (Kelly, Taplin, & Allen, 1971). Treatment
consists of oral cloxacillin, cephalexin or erythromycin for 1 to 2 weeks (Galen et
al., 1995). (Grade B, Level III)
GPP - Local cleansing with chlorhexidine twice daily is helpful.
Blistering dactylitis
B - Blistering dactylitis is usually caused by Streptococcus pyogenes (Hays &
Mullard, 1975). Treatment involves incision and drainage of large blisters, and a 7
to 10 day course of penicillin V (25-50 mg/kg/day divided 6hrly), amoxycillin (20-
50mg/kg/day divided 8hrly) or erythromycin (Galen et al., 1995; Wortman,
1993). (Grade B, Level III)
Folliculitis
B - Folliculitis is commonly caused by Staphylococcus aureus. Treatment consists
of chlorhexidine wash and oral cloxacillin, cephalexin or erythromycin for 7 to 10
days (Wortman, 1993). (Grade B, Level III)
Furunculosis and carbuncles
B - Furunculosis and carbuncles are infection of hair follicles by Staphylococcus
aureus
. Larger lesions should be incised and drained if fluctuant (Dahl, 1987).
Appropriate antibiotics include cloxacillin, cephalexin or erythromycin for 7 to 10
days or until inflammation has subsided (Kelly, Taplin, & Allen, 1971; Wortman,
1993). (Grade B, Level III)
B - Other measures include eliminating predisposing factors, using chlorhexidine
cleanser, iron supplementation for refractory furunculosis with low serum iron and
eliminating nasal carriage with chlorhexidine, bacitracin, tetracycline or 2%
mupirocin ointment. However, long term and unrestricted use of mupirocin has
been associated with the development of mupirocin resistance (Mandell, Benett, &
Dolin, 2000). Therefore judicious use is advocated and only in methicillin-resistant
Staphylococcus aureus (MRSA) carriers. (Grade B, Level IIa)
Cellulitis and erysipelas
B - Cellulitis and erysipelas can be treated with a combination of amoxycillin plus
cloxacillin, cephalexin, erythromycin, or a combination of intravenous crystalline
penicillin G (100,000-250,000 units/kg/day divided 6hrly) and cloxacillin. (Grade
B, Level III
)
For facial/periorbital cellulitis in young children, admission to hospital is warranted and the following antibiotics are recommended: B - Intravenous ampicillin/sulbactam (150mg/kg/day divided 8hrly) (Kanra et al.,
1996) (Grade B, Level III)
C - Ceftriaxone (50-100 mg/kg/day intravenously divided 12-24hrly) (Grade C,
Level IV
)
Perianal streptococcal dermatitis
C - The recommended therapy for perianal streptococcal dermatitis is oral
penicillin V, amoxycillin or erythromycin for 10 to 14 days (Barnett & Frieden,
1992). (Grade C, Level IV)
Necrotising fasciitis
C - Necrotising fasciitis is a medical emergency. Prompt surgical debridement is
the most important aspect of therapy. High dose intravenous penicillin G
(250,000-450,000 units/kg/day divided 4-6hrly) is used to treat Group A
streptococcal infection. Additional antibiotics will depend on clinical assessment
and culture results (Rathore, Barton, & Kaplan, 1992; Stevens, 1994). (Grade C,
Level IV
)
Staphylococcal scalded skin syndrome
C - Treatment includes hospitalisation, supportive measures and cloxacillin
(Rudolph, Schwartz, & Leyden, 1974). (Grade C, Level IV)
Toxic shock syndrome
C - Besides hospitalisation, intravenous fluid support, cloxacillin + clindamycin
(25-40mg/kg/day divided 8hrly) is used in staphylococcal toxic shock syndrome
(TSS) (Mandell, Benett, & Dolin, 2000; Resnick, 1992) and penicillin G and
clindamycin in streptococcal toxic shock syndrome (Stevens et al., 1988). (Grade
C, Level IV
)
Methicillin-resistant Staphylococcus aureus infection
A - For nasal colonisation, topical mupirocin or topical fusidic acid plus oral
cotrimoxazole can be used (Parras et al., 1995). (Grade A, Level Ib)
C - For mild to moderate infections, guided by culture sensitivity results, a
combination of at least 2 oral antibiotics--fusidic acid (20-50mg/kg/day every
8hrly), clindamycin (10-40mg/kg/day divided 8hrly), cotrimoxazole (contra-
indicated in children with G6PD deficiency), or minocycline (1-2 mg/kg/day
divided 12hrly; not recommended for children younger than 8 years old) are
recommended. (Grade C, Level IV)
C - For moderate to severe infection, vancomycin (40-60mg/kg/day divided 8-
12hrly) is the antibiotic of choice. (Grade C, Level IV)
Definitions:
Grades of Recommendation
Grade A (evidence levels Ia, Ib) Requires at least one randomised controlled trial
as part of the body of literature of overall good quality and consistency addressing
the specific recommendation.
Grade B (evidence levels IIa, IIb, III) Requires availability of well conducted
clinical studies but no randomised clinical trials on the topic of recommendation.
Grade C (evidence level IV) Requires evidence obtained from expert committee
reports or opinions and/or clinical experiences of respected authorities. Indicates
absence of directly applicable clinical studies of good quality.
GPP (good practice points) Recommended best practice based on the clinical
experience of the guideline development group.
Levels of Evidence
Ia Evidence obtained from meta-analysis of randomised controlled trials.
Ib Evidence obtained from at least one randomised controlled trial.
IIa Evidence obtained from at least one well-designed controlled study without
randomisation.
IIb Evidence obtained from at least one other type of well-designed quasi-
experimental study.
III Evidence obtained from well-designed non-experimental descriptive studies,
such as comparative studies, correlation studies and case studies, committee
reports or opinions and/or clinical experiences of respected authorities.
IV Evidence obtained from expert committee reports or opinions and/or clinical
experiences of respected authorities.
CLINICAL ALGORITHM(S)
The original guideline contains clinical algorithms for 1) the management of urinary tract infections in children; 2) approach to acute gastroenteritis. EVIDENCE SUPPORTING THE RECOMMENDATIONS
REFERENCES SUPPORTING THE RECOMMENDATIONS
TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS
The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations"). BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS
POTENTIAL BENEFITS
The indiscriminate or inappropriate use of antibiotics can accelerate the development of anti-microbial resistant bacterial strains. This has become an increasing source of concern for public health and infectious disease specialists as multi-drug resistance may be the Achilles heel in our war against bacteria. The judicious use of antibiotics (e.g. appropriate indications, selection and recommended dosages) is therefore an important way to reduce the problem of anti-microbial resistance. POTENTIAL HARMS
Cotrimoxazole has a higher incidence of adverse drug reactions compared to cloxacillin or erythromycin. CONTRAINDICATIONS
CONTRAINDICATIONS
• Tetracycline is contra-indicated in children younger than 8 years of age. However, in severe diarrhoea, the benefits may outweigh the risk of staining the developing teeth. • Cotrimoxazole is contra-indicated in children with glucose-6-phosphate- QUALIFYING STATEMENTS
QUALIFYING STATEMENTS
• These guidelines are not intended to serve as a standard of medical care. Standards of medical care are determined on the basis of all clinical data available for an individual case and are subject to change as scientific knowledge advances and patterns of care evolve. • The contents of this publication are guidelines to clinical practice, based on the best available evidence at the time of development. Adherence to these guidelines may not ensure a successful outcome in every case, nor should they be construed as including all proper methods of care or excluding other acceptable methods of care. Each physician is ultimately responsible for the management of his/her unique patient in the light of the clinical data presented by the patient and the diagnostic and treatment options available. • These guidelines serve as an aid to clinical practice and are not meant to be comprehensive, nor do they address all available antibiotics. High-risk patients such as those who are immunocompromised, have chronic debilitating disease or serious cardiopulmonary conditions are not covered in these guidelines. As disease states evolve, patient evaluation is important and the individual medical practitioner has to tailor the management to obtain the best outcome. The physician in charge should decide carefully the appropriate choice when antibiotics are indicated. It should be noted that the correct choice of an antibiotic would depend on the clinical picture of the patient as well as the bacterial culture and sensitivity. It must be recognised that disease states may evolve along different paths and therefore, periodic patient evaluation is very important. IMPLEMENTATION OF THE GUIDELINE
DESCRIPTION OF IMPLEMENTATION STRATEGY
An implementation strategy was not provided. IMPLEMENTATION TOOLS
For information about availability, see the "Availability of Companion Documents" and "Patient Resources" fields below. INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES
IOM CARE NEED
IOM DOMAIN
IDENTIFYING INFORMATION AND AVAILABILITY
BIBLIOGRAPHIC SOURCE(S)
Singapore Ministry of Health. Use of antibiotics in paediatric care. Singapore: Singapore Ministry of Health; 2002 Mar. 109 p. [193 references] ADAPTATION
Not applicable: The guideline was not adapted from another source. DATE RELEASED
GUIDELINE DEVELOPER(S)
Singapore Ministry of Health - National Government Agency [Non-U.S.] SOURCE(S) OF FUNDING
GUIDELINE COMMITTEE
Workgroup on Use of Antibiotics in Paediatric Care COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE
Workgroup Members: Dr Phua Kong Boo (Chairman); Dr June Lou; Dr Warren Lee; Dr Anne Goh Eng Kim; Dr Chao Sing Ming; Dr Ho Lai Yun; Dr Lim Fong Seng; Dr Lim Kim Whee; Prof Low Poh Sim; Dr Matthew Ng; Dr Simon Ng Pau Ling; Dr Steven Ng; Dr Winston Ng; Dr Ong Eng Keow; Dr Ooi Boo Chye; Prof Quak Seng Hock; Dr Lynette Shek; Dr Sim Sze Keen; Dr Tan See Leng; Dr Agnes Tay; Dr Tay Yong Kwang; Prof Ti Tiow Yee; Dr Yip Yeng Yoong; Mr Yeoh Siang Fei; Dr Allen Wang (Secretariat) FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST
GUIDELINE STATUS
This is the current release of the guideline. GUIDELINE AVAILABILITY
Electronic copies: Available in Portable Document Format (PDF) from the gapore Ministry of Health Web site. Print copies: Available from the Singapore Ministry of Health, College of Medicine Building, Mezzanine Floor 16 College Rd, Singapore 169854. AVAILABILITY OF COMPANION DOCUMENTS
PATIENT RESOURCES
NGC STATUS
This NGC summary was completed by ECRI on May 20, 2003. The information was verified by the guideline developer on June 3, 2003. COPYRIGHT STATEMENT
This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions. Please contact the Ministry of Health, Singapore by e-mail at . 1998-2005 National Guideline Clearinghouse

Source: http://www.pneumologiamo.it/materiale/01_04_06/marchioni/pdf-1.pdf

Pii: s0140-6736(02)11208-6

e-mail submissions to correspondence@lancet.comSir—Björn Dahlöf, in the LIFE study,1Lars Lindholm and colleagues “to share exciting news” and remindme of the results of the LIFE study. cardiologists received the same letter. Iporosity of liver sinusoids in relation toloss of integrity of the endothelial lining,Dahlöf B, Devereux RB, Kjeldsen SE, et al. Cardiovascular morbidity and

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