By Nicole Pietraszewski PharmD Candidate,

Community acquired pneumonia (CAP) is the cause of about 1.5 million pediatric medical visits each year and remains the second-leading cause of pediatric hospitalizations in the United States.¹ The 2011  Pediatric Infectious Disease Society and Infectious Diseases Society of America (PIDS/IDSA) guideline for pediatric CAP, currently archived, recommends a 10-day treatment course for most patients, as available evidence at the time supported that duration.² Although the guideline acknowledged that shorter courses might be effective for uncomplicated outpatient cases and could help limit resistance, it has not been updated to reflect more recent data supporting shorter treatment durations.²

Importantly, the 2024 Report of the Committee on Infectious Diseases of the American Academy of Pediatrics (AAP Red Book)  currently recommends a 5-day treatment duration for uncomplicated CAP, while recognizing that longer courses remain appropriate for complicated infection.³ This guidance sets the stage for pharmacists to help standardize shorter, evidence-based CAP treatment durations across outpatient settings.

What do different guidelines recommend for pediatric outpatient CAP?

Other guidance has moved toward shorter (3-5 day) antibiotic courses for outpatient pediatric CAP.^4,5 Both the World Health Organization (WHO) and the United Kingdom’s National Institute for Health and Care Excellence (NICE) published guidelines in 2024 and 2025, and respectively recommend this short duration.^4,5

What evidence is there for short-duration treatment for pediatric outpatient CAP?

A large meta-analysis published compared short-duration treatment (3-5 days) versus long-duration treatment (5-10 days) antibiotic therapy in children (<18 years old) with CAP.¹ The analysis included 16 randomized controlled trials, published from inception to April 30, 2022, with a total of 12,774 patients.¹

Shorter antibiotic courses had similar outcomes as longer ones.¹ There was no significant difference found in the odds of clinical cure (n=7,298; OR 1.01, 95% CI 0.87 to 1.17), risk of treatment failure which included generally worsening or non-improving illness requiring treatment change, hospitalization (n=10,303; RR 1.06, 95% CI 0.93 to 1.21), mortality (n=9,058; RD 0.0%, 95% CI -0.2 to 0.1), or adverse effects (n=2,249; RR 0.75, 95% CI 0.44 to 1.28).¹ The subgroup analysis showed no differences by age, same or different drug class, and high or low income countries.¹

A more focused CAP meta-analysis included all high-income country trials namely CAP-IT, SCOUT-CAP, SAFER, and the 2014 Greenberg trial.^1,6 The meta-analysis, which is more applicable to US patients based on population and treatments, evaluated randomized controlled trials published from 2003 to 2022, concluded that 3-5 days was as safe and effective as 7-10 days in patients with uncomplicated CAP.⁶ It only included trials comparing beta-lactam therapies, consistent with PIDS/IDSA and AAP Red Book recommendations that amoxicillin is first-line for non-severe CAP.^2,3,6

Populations of Focused CAP Meta-Analysis

Effect of Amoxicillin Dose and Treatment Duration on the Need for Antibiotic Re-treatment in Children with Community-Acquired Pneumonia: a randomized controlled trial (CAP-IT): children aged ≥ 6 months (6-24 kg) diagnosed with CAP and discharged within 48 hours on amoxicillin monotherapy7 3 vs 7 days of amoxicillin 35-50 mg/kg/day divided twice daily 3 vs 7 days of amoxicillin 70-90 mg/kg/day divided twice daily

Short- vs Standard-Course Outpatient Antibiotic Therapy for Community-Acquired Pneumonia in Children: a randomized controlled trial (SCOUT-CAP): children aged 6-71 months with outpatient uncomplicated CAP and prescribed amoxicillin, amoxicillin-clavulanate, or cefdinir all divided twice daily8 5 vs 10 days of amoxicillin 80-100mg/kg/day, amoxicillin-clavulanate 80-100mg/kg/day or cefdinir 12-16 mg/kg/day

Short-Course Antimicrobial Therapy for Pediatric Respiratory Infections: a randomized controlled trial (SAFER): children aged 6 months to 10 years with CAP that did not require hospitalization and prescribed amoxicillin monotherapy9 5 vs 10 days of amoxicillin 75-100 mg/kg/day divided three times daily

Short-course antibiotic treatment for community-acquired alveolar pneumonia in ambulatory children: a randomized controlled trial: children aged 6-59 months with CAP that did not require hospitalization10 3 vs 10 days of amoxicillin 80 mg/kg/day divided three times daily 5 vs 10 days of amoxicillin 80 mg/kg/day divided three times daily

This analysis found no difference between either treatment failure, defined as the need for antibiotic retreatment one month after initial course or hospitalization (n=1,541; RD -0.00, 95% CI -.03 to 0.02), or in adverse effects (n=1,194; RD -0.00, 95% CI -.05 to 0.05). ⁶

Overall, recent evidence supports 3 to 5 day beta-lactam treatment for children of at least 6 months old with uncomplicated CAP, primarily outpatient.

What does this mean for practice and what’s next?

Antimicrobial stewardship programs in the inpatient arena have demonstrated strong improvements in antimicrobial prescribing.  This strong evidence, specific to pediatric CAP, provides an opportunity for pharmacists in ambulatory settings (e.g., community, clinics, emergency departments) to improve review their current practice, and if warranted implement antimicrobial stewardship efforts to reduce routine prescribing to 3-5 day durations of amoxicillin for most pediatric outpatient CAP cases,

About the author: Nicole Pietraszewski, is a Doctor of Pharmacy candidate at the University of Connecticut. This post was written as part of her Advanced Pharmacy Practice Experience under the guidance of her professor, Jennifer Girotto PharmD, BCPPS, BCIDP, who also reviewed and edited the piece.

References

1. Gao Y, Liu M, Yang K, et al. Shorter versus longer-term antibiotic treatments for community-acquired pneumonia in children: A meta-analysis. Pediatrics. 2023;151(6):e2022060097. doi: 10.1542/peds.2022–060097. doi: 10.1542/peds.2022-060097.
2. Bradley JS, Byington CL, Shah SS, et al. Executive summary: The management of community-acquired pneumonia in infants and children older than 3 months of age: Clinical practice guidelines by the pediatric infectious diseases society and the infectious diseases society of america. Clin Infect Dis. 2011;53(7):617–630. doi: 10.1093/cid/cir625.
3. Systems-based treatment tableCommittee on Infectious Diseases, American Academy of Pediatrics, Kimberlin DW, Banerjee R, Barnett ED, Lynfield R, Sawyer MH, eds. Red book: 2024–2027 report of the committee on infectious diseases. American Academy of Pediatrics; 2024:0. https://doi.org/10.1542/9781610027373-TAB. Accessed 2/9/2026. 10.1542/9781610027373-TAB.
4. World Health Organization. Guideline on management of pneumonia and diarrhoea in children up to 10 years of age. 2024. https://iris.who.int/server/api/core/bitstreams/bddcc725-8ffd-4d38-bec4-d6ead2904911/content.
5. National Institute for Health and Care Excellence. Pneumonia: Diagnosis and
   management. 2025.
6. Kuitunen I, Jääskeläinen J, Korppi M, Renko M. Antibiotic treatment duration for community-acquired pneumonia in outpatient children in high-income countries-A systematic review and meta-analysis. Clin Infect Dis. 2023;76(3):e1123–e1128. doi: 10.1093/cid/ciac374.
7. Bielicki JA, Stöhr W, Barratt S, et al. Effect of amoxicillin dose and treatment duration on the need for antibiotic re-treatment in children with community-acquired pneumonia: The CAP-IT randomized clinical trial. JAMA. 2021;326(17):1713–1724. doi: 10.1001/jama.2021.17843.
8. Williams DJ, Creech CB, Walter EB, et al. Short- vs standard-course outpatient antibiotic therapy for community-acquired pneumonia in children: The SCOUT-CAP randomized clinical trial. JAMA Pediatr. 2022;176(3):253–261. doi: 10.1001/jamapediatrics.2021.5547.
9. Pernica JM, Harman S, Kam AJ, et al. Short-course antimicrobial therapy for pediatric community-acquired pneumonia: The SAFER randomized clinical trial. JAMA Pediatr. 2021;175(5):475–482. doi: 10.1001/jamapediatrics.2020.6735.
10. Greenberg D, Givon-Lavi N, Sadaka Y, Ben-Shimol S, Bar-Ziv J, Dagan R. Short-course antibiotic treatment for community-acquired alveolar pneumonia in ambulatory children: A double-blind, randomized, placebo-controlled trial. Pediatr Infect Dis J. 2014;33(2):136–142. doi: 10.1097/INF.0000000000000023.

 

 

The Surgical Infection Society (SIS) Guidelines on the Prevention and Management of Pediatric Intra-Abdominal Infection Update was just published.¹ These authors note that these are to be used in conjunction with the prior guidelines, as many aspects have not changed. Source control remains essential. For treatment they continue to recommend the combination of ceftriaxone (or cefotaxime, if available) with metronidazole or monotherapy with ertapenem for lower-risk infants, children, and adolescents. After achievement of source control, antibiotic duration in patients beyond the neonatal period (i.e., > 45 weeks post conceptional age), should be limited to 5 days.¹ In cases of perforated appendicitis complicated by post-operative abscess, the guideline recommends antibiotic duration should not exceed 7 days. Therapy should be transitioned to oral agents with high bioavailability as early as feasible.  The guidelines also discuss risk categories, although their definition includes some elements that are adult focused (e.g., advanced age), most of the high-risk features (e.g., septic shock, delayed or inadequate source control, post-operative intra-abdominal infections, multiple medical comorbidities or cancer, those with a history of a multi-drug resistant organism) are directly applicable to the pediatric population.¹

What is currently recommended for treatment of intra-abdominal infections per SIS?

How should we treat infants?

The guidelines made specific recommendations for the treatment of two groups of infants. The first was preterm infants.¹ This is based on findings of no differences reported in clinical outcomes from an open label, multicenter trial that included infants (n=180) that were ≤ 33 weeks gestational age and <121 days old.^1,2 The antibiotic regimens included in the study and recommended for preterm infants with intra-abdominal infection (primarily necrotizing enterocolitis) are: ampicillin and gentamicin with either metronidazole or clindamycin or piperacillin-tazobactam with gentamicin.^1,2  Although the first 2 regimens are standard, the rational for the study combining gentamicin with the piperacillin-tazobactam, resulting in dual Gram-negative coverage, is not entirely clear.  The second infant recommendation is that metronidazole is the anti-anaerobic agent of choice for combination therapy in infants.¹ This recommendation was based on a multicenter open label trial that included infants of ≥34 weeks gestational age and < 121 days old.^1,3 All patients received metronidazole as part of their intra-abdominal infection treatment. The panel cited high overall cure rates (98%) along with low rates of death (2%), intestinal perforation (2%), and intestinal stricture (2%).^1,3

What about empiric treatment of older infants, children and adolescents

For empiric therapy of intra-abdominal infection in older pediatric patients.¹ The guidelines recommend having antimicrobial stewardship protocols in place to help improve appropriateness of antibiotic choice. Data further suggest that enterococcal specific targeted therapy is not needed.

For empiric choices of antibiotics in those with low-risk disease, they recommend ceftriaxone (or cefotaxime, where available) both in combination with metronidazole or monotherapy with ertapenem.¹ In patients who meet high-risk criteria the guidelines did add the broad-spectrum cephalosporin-beta-lactamase combinations: ceftolozane/tazobactam and ceftazidime-avibactam based on small outcome studies used to obtain pediatric FDA approval for intra-abdominal infections.^1,4,5 Note that the guidelines suggest, and antimicrobial stewardship principles strongly recommend protecting and reserving these agents when the patient is at high risk, such as those with known resistance to usual agents.¹

Antimicrobial therapy the SIS guidelines recommend against moxifloxacin for empiric therapy.^1,6  This recommendation authors note was due to a combination of increased rate of antibiotic attributed adverse effects (14% vs 7%) and lower cure rates (85% vs 96%).^1,6

What are the recommendations for perforated appendicitis?

Different antibiotics (i.e., piperacillin-tazobactam or ertapenem) are recommended by the SIS for perforated appendicitis.¹  The panel did not endorse the use of ceftriaxone and metronidazole for perforated appendicitis, comparing the 2 in pediatrics. The IMPACT study found that piperacillin-tazobactam had significantly lower rates of post-operative intra-abdominal abscesses (6% vs 24%), need for post-op CT scanning (14% vs 30%), emergency department visits (9% vs 26%).^1,7 Further, authors reported the choice of medication was most significant predictor of the intra-abdominal post-operative abscess formation.^1,7 However, the evidence is not entirely one-sided. A 2025 meta-analysis published after the SIS pulled their study data, incorporating the IMPPACT trial and 3 retrospective studies did not find significant differences between antibiotic regimens. Because 3 of the 4 studies were observational, there is some concern for selection bias.⁸  As such, the question may still be up for debate.

The randomized study supporting ertapenem’s inclusion, compared it versus gentamicin and metronidazole, a regimen not commonly used for pediatric perforated appendicitis in the US.^1,9 While patients who received the ertapenem became afebrile 2 days sooner, no differences were reported for other clinical outcomes.^1,9 This study is important, but also raises some generalizability questions about how it compares to currently used regimens.

That said, the evidence in this area remains nuanced.  It will be interesting to see how the upcoming Infectious Diseases Society of America intra-abdominal infection guidelines update addresses these same questions.

When can therapy be transitioned to PO?

Data support transitioning from intravenous to oral therapy once source control is achieved in pediatric patients with perforated disease.¹ In the pediatric studies supporting this recommendation, commonly used oral antibiotics included amoxicillin/clavulanate monotherapy or trimethoprim/sulfamethoxazole with metronidazole.¹

Key Stewardship Takeaways

This update to the SIS recommendations for pediatric patients with intra-abdominal infections summarizes the current literature and highlights the importance of antimicrobial stewardship including having established protocols, choice of antimicrobial therapy, and evidence-based transition to oral therapy for pre-determined durations.  Although there are nuanced considerations, overall, it provides guidance to help support improved patient care in this area.

References

1. Huston JM, Forrester JD, Barie PS, et al. Surgical Infection Society Guidelines on the Prevention and Management of Pediatric Intra-Abdominal Infection: 2025 Update. Surg Infect (Larchmt). 2026;27(1):5–15.
2. Smith MJ, Boutzoukas A, Autmizguine J, et al. Antibiotic Safety and Effectiveness in Premature Infants With Complicated Intraabdominal Infections. Pediatr Infect Dis J. 2021;40(6):550–555.
3. Commander SJ, Gao J, Zinkhan EK, et al. Safety of Metronidazole in Late Pre-term and Term Infants with Complicated Intra-abdominal Infections. Pediatr Infect Dis J. 2020;39(9):e245–e248.
4. Bradley JS, Broadhurst H, Cheng K, et al. Safety and Efficacy of Ceftazidime-Avibactam Plus Metronidazole in the Treatment of Children ≥3 Months to <18 Years With Complicated Intra-Abdominal Infection: Results From a Phase 2, Randomized, Controlled Trial. >Pediatr Infect Dis J. 2019;38(8):816–824.
5. Jackson CA, Newland J, Dementieva N, et al. Safety and Efficacy of Ceftolozane/Tazobactam Plus Metronidazole Versus Meropenem From a Phase 2, Randomized Clinical Trial in Pediatric Participants With Complicated Intra-abdominal Infection. Pediatr Infect Dis J. 2023;42(7):557–563.
6. Wirth S, Emil SGS, Engelis A, et al. Moxifloxacin in Pediatric Patients With Complicated Intra-abdominal Infections: Results of the MOXIPEDIA Randomized Controlled Study. Pediatr Infect Dis J. 2018;37(8):e207–e213.
7. Lee J, Garvey EM, Bundrant N, et al. IMPPACT (Intravenous Monotherapy for Postoperative Perforated Appendicitis in Children Trial): Randomized Clinical Trial of Monotherapy Versus Multi-drug Antibiotic Therapy. Ann Surg. 2021;274(3):406–410.
8. Armstrong J, Sriranjan J, Briatico D, et al. Piperacillin/tazobactam versus ceftriaxone/metronidazole for children with perforated appendicitis: a systematic review and meta-analysis. Pediatr Surg Int. 2025;42(1):3–z.
9. Pogorelić Z, Silov N, Jukić M, et al. Ertapenem Monotherapy versus Gentamicin Plus Metronidazole for Perforated Appendicitis in Pediatric Patients. Surg Infect (Larchmt). 2019;20(8):625–630.

 

Measles, a disease that was a rare occurrence in the recent past, has become much more common beginning in 2025. As I have received many questions about measles vaccine and treatment options, I thought it would be a good initial topic to discuss in early 2026.

Measles Cases Continuing to Increase

The incidence of measles in the US and many developed countries has been on the rise. In 2025 the US, the Centers for Disease Control and Prevention have noted 2276 cases in 44 states.¹ Most cases (68%) were in children, and the youngest children (<5 years old) have the highest rates of hospitalization (20%).¹ In early 2026, these increases continue with 733 cases by February 5, 2026.¹

Measles Vaccine is Very Effective

The measles, mumps, and rubella (MMR) vaccine is a very effective live attenuated vaccine.  One dose of MMR is about 90% effective and 2 doses 97%.^2,3  Without appropriate immunity (primarily obtained from vaccination), measles is very contagious, causing disease in more than 90% of exposed individuals.³

MMR vaccination is routinely recommended as a 2-dose series (dose 1 at 12-15 months of age, dose 2 at 4-6 years).^4-6 Doses as close as 28 days apart are considered valid.  The MMR vaccine is also recommended for susceptible individuals as young as 6 months of age during an outbreak (consult local public health for specifics) or in those planning international travel (doses given prior to 12 months of age do not count towards 2 routine dose recommendation).^7,8

How does measles disease present?

Measles has an initial prodrome when symptoms can be similar to a severe cold or flu with fever (often high), cough, runny nose, and conjunctivitis.^3,7 The characteristic Koplik spots may be present during the prodrome or may become present a day or two later. The rash, which begins in the head/facial area and spreads downward has been one of the most obvious symptoms of measles, does not present until 2-5 days into the illness. Thus, besides being very contagious, another reason patients transmit it to others is they may not think they have measles while they are most contagious. In healthy individuals, the infectious period is 4 days before and 4 days after the rash appears.^3,7

Measles can have complications and infants and young children are at risk for these. The most common complications include diarrhea, ear infections and pneumonia.³ Important, but rare complications include acute encephalitis as well as a late onset (7-10 years later) fatal complication of subacute sclerosing panencephalitis.³

What can I do if susceptible children are exposed?

Vaccines and measles immunoglobulin can be helpful at protecting exposed patients, if the patient is aware and can obtain it in time. The vaccine is the preferred recommendation (84 – 100% effectiveness) in non-immune eligible patients (i.e., ≥ 6 months and without contraindications) who were exposed in the prior 72 hours.^7,9 Immune globulin is recommended (76-100% effectiveness) for those who have a risk factor and are unable to receive the vaccine due to age (e.g., < 6 months), timing (e.g., > 72 hours but < 5 days), or contraindication to the vaccine (e.g., immunocompromise, pregnancy).^7,9

Are there any treatments for measles?

There are no antivirals that have efficacy against measles.  Data from a 2025 Cochrane review on the use of vitamin A for the treatment of measles, relied on limited studies published in the 1980’s and 1990’s.¹⁰ In their review of the studies they found that two doses of vitamin A at 200,000 IU did not result in overall lower risk of mortality; however, it was associated with lower mortality in young children (e.g., < 2 years) and in those who had measles associated pneumonia.¹⁰ It also had a slight reduction in measles croup.  The vitamin A was not, however, effective at preventing pneumonia and had only a non-significant impact on the duration of pneumonia.¹⁰

Summary

It is important to make sure that all are aware that measles is preventable by a highly effective routine immunization recommended in childhood.  Catch-up vaccination can be given to all those without protection as long as they do not have any contraindications.  When individuals contract measles disease there are no specific treatments, although a 2-dose series of vitamin A may help in some circumstances.

References

1. Centers for Disease Control and Prevention. Measles Cases and Outbreaks. Accessed February 6, 2026https://www.cdc.gov/measles/data-research/
2. Paul Gastanaduy, Penina Haber, Paul Rota, Manisha Patel. Chapter 13: Measles. In: Elisha Hall, A. Patricia Wodi, Jennifer Hamborsky, Valerie Morelli, Sarah Schille, eds. The Epidemiology and Prevention of Vaccine-Preventable DiseasesPublic Health Foundation; 2024
3. James L. Goodson and Thomas D. Filardo. Measles (Rubeola). In: Centers for Disease Control and Prevention (CDC), ed. CDC Yellow Book 2026: Health Information for International Travel.2026th ed. https://www.cdc.gov/yellow-book/hcp/travel-associated-infections-diseases/measles-rubeola.html
4. American Academy of Family Physicians. Immunization Schedules. Accessed December 12, 2025 https://www.aafp.org/family-physician/patient-care/prevention-wellness/immunizations-vaccines/immunization-schedules.html
5. American Academy of Pediatrics, Committee on Infectious Diseases. Red Book : Report of the Committee on Infectious Diseases 2024 – 2027. AAP Immunization Schedule. Accessed December 12, 2025 https://publications.aap.org/redbook/resources/15585/AAP-Immunization-Schedule
6. Centers for Disease Control and Prevention. Child and Adolescent Immunization Schedule by Age (Addendum updated August 7, 2025). Accessed September 20, 2025 https://www.cdc.gov/vaccines/hcp/imz-schedules/child-adolescent-age.html
7. Committee on Infectious Diseases, American Academy of Pediatrics. Measles. In: David W Kimberlin, Ritu Banerjee, Elizabeth D Barnett, Ruth Lynfield, Mark H. Sawyer, eds. Red Book: 2024–2027 Report of the Committee on Infectious Diseases (33rd Edition) American Academy of Pediatrics; 2024
8. Mathis AD, Raines K, Filardo TD, et al. Measles Update – United States, January 1-April 17, 2025. MMWR Morb Mortal Wkly Rep. 2025;74(14):232–238
9. Montroy J, Yan C, Khan F, et al. Post-exposure prophylaxis for the prevention of measles: A systematic review. Vaccine. 2025;47:126706
10. Huiming Y, Chaomin W, Meng M. Vitamin A for treating measles in children. Cochrane Database Syst Rev. 2005;2005(4):CD001479

By Kenna Riley PharmD Candidate,  

Bacterial arthritis (e.g., septic arthritis) is caused by bacteria entering the joint from the bloodstream, causing infection and inflammation of the joint and synovial fluid.​¹​ It requires prompt antibiotic treatment to prevent severe outcomes, such as irreversible joint damage.  In 2023, the Pediatric Infectious Diseases Society (PIDS) and the Infectious Diseases Society of America (IDSA) published a guideline to provide recommendations on diagnosis and treatment strategies to improve patient outcomes.¹ The purpose of this writing is to summarize the key points in that guideline and summarize any emerging data.

Antimicrobial Recommendations

Bacterial arthritis generally affects a single joint (e.g., knee) and presents with sudden onset fever, joint pain, swelling, and immobility.​¹​ Those who are most at risk include children under 3 years, males, those with recent trauma, and individuals with a weakened immune system (e.g., prematurity, sickle cell disease, or HIV).​¹​To improve the likelihood of identifying a pathogen, it is recommended, when clinically reasonable, to obtain a full work up (e.g., blood culture, synovial fluid culture/analysis, C-reactive protein, imaging) prior to the initiation of empiric antibiotics.​¹​

Staphylococcus aureus is the most common cause of bacterial arthritis in children.​¹​ Kingella kingae is another causative pathogen, that has up until recently been unable to be identified, but with recent technology with improved diagnostics this is now feasible.²​​ K. kingae is most commonly seen in children 6 months to 5 years old.^1,2 These two pathogens luckily is often present a bit differently. When bacterial arthritis is caused by S. aureus it typically has a rapid and aggressive onset, with joint pain that quickly worsens over 24 to 48 hours.​^1,2 Whereas K. kingae infections have a more gradual onset with symptoms at presentation often being less severe.​​²

 

Treatment of Bacterial Arthritis

PIDS/IDSA guidelines recommend empiric therapy to cover S. aureus.¹​ It is important to consider pediatric methicillin-resistant S. aureus (MRSA) rates, especially community-associated MRSA as these vary by region. In areas with low MRSA prevalence (e.g., <10-15% of community-acquired S. aureus infections), guidelines recommend empiric treatment with either a first-generation cephalosporin (e.g., cefazolin) or an anti-staphylococcal penicillin (e.g., nafcillin, oxacillin).¹  In contrast, in regions with high MRSA prevalence, it’s essential to empirically include an agent with strong MRSA activity, such as clindamycin (if high rates of susceptibility) or vancomycin.​​ In those who are 6 months to less than 4 years old, it is suggested to ensure coverage also includes K. kingae (which is already covered if cefazolin is chosen) by adding an agent such as ampicillin to either clindamycin or vancomycin therapies.​¹

When choosing an antibiotic, it’s important to understand each antibiotic’s risks vs benefits. Starting with the antibiotics used in areas with lower MRSA rates. Penicillins and cephalosporins are time-dependent killing drugs and efficacy is best predicted by the amount of time the antibiotic’s concentration remains above the minimum inhibitory concentration (T>MIC). The anti-staphylococcal penicillins require frequent administration every 4 to 6 hours and are associated with adverse effects such as phlebitis, interstitial nephritis, as well as hematologic suppression (e.g., anemia, neutropenia) when used for longer periods (e.g., > 14 days). In contrast, cefazolin offers a more convenient dosing schedule, administered every 8 hours, while still maintaining a strong safety profile and efficacy against MSSA and K. kingae.​

Another key antibiotic often used in treatment, particularly for suspected methicillin-resistant S. aureus (MRSA) infections, is vancomycin. This is a good first choice when highly reliable MRSA coverage is needed. Vancomycin is the preferred antimicrobial agent for clindamycin-resistant CA-MRSA infections when initial parenteral therapy is required.¹ It requires therapeutic drug monitoring due to its narrow therapeutic index and nephrotoxicity risk. On the other hand, clindamycin is a great alternative with excellent oral bioavailability, making it optimal when susceptible, especially for outpatient management. However, clindamycin resistance may be a concern, depending on the local resistance rates and must be weighed into decision making. Ultimately, the choice between these two agents is determined by the severity of the infection, local susceptibility rates, and the need to balance their risks and benefits.

It is also important to note that the guidelines do not recommend the use of adjunctive corticosteroids. There is insufficient evidence to support their benefit, and they may suppress the immune system, hindering the body’s ability to clear the infection.

In addition to what therapies to use and avoid, therapy duration is another important consideration.  The guidelines state that the total duration of therapy is variable and depends on a patient’s clinical and laboratory response to treatment, as well as the specific pathogen. For patients who show rapid clinical improvement and a trending decrease in C-reactive protein (CRP) by the end of the first treatment week, a shorter course of 10 to 14 days is often sufficient.¹ However, if a patient has a slower clinical response, has inadequate source control, or has persistently elevated CRP levels, a longer course of 21 to 28 days may be preferred to ensure the infection is completely cleared.​¹ This approach allows for adjustments in therapy duration as the patient’s condition evolves, ensuring both efficacy and patient safety.

Areas of Uncertainty & Emerging Evidence

While the new guideline provides a strong framework, it also highlights areas of clinical uncertainty. Future research is needed to improve the diagnostic accuracy of laboratory tests, better define the role of advanced molecular pathogen identification, and establish an optimal duration for antibiotic therapy. These gaps underscore that while guidelines are a vital resource, they also serve as a road map for future research to refine and improve the care of children with septic arthritis.

The 2023 PIDS/IDSA guidelines for pediatric acute bacterial arthritis are recently published and there has been limited new evidence that would significantly result in many changes. A notable study was published in 2024 that supports initial oral therapy.   A nationwide, randomized controlled trial from September 2020 to June 2023 in Denmark evaluated non-severe uncomplicated bone and joint infections (~40% were joint infections) comparing initial therapy of intravenous ceftriaxone 100 mg/kg/day once daily or oral therapy with amoxicillin/clavulanate 100/12.5 mg/kg/day in three daily doses in children 3 months to 5 years or dicloxacillin 200 mg/kg/day in four daily doses in children 5 to 17 years.  Patients in both groups were changed to standard dose oral therapy after at least 3 days of therapy and demonstration of clinical and laboratory improvement.  Approximately 40% of the patients had joint infections with 25% identifying a specific pathogen (S. aureus 14-16% – only 1 of which had MRSA and K. kingae 5-9%).  Total duration of antibiotics for joint infections were 12.6 (10.3 – 19.4) high dose oral therapy and 10.6 (9.8-14.2) days initial intravenous therapy.  No patients met the study designed criteria of sequelae after 6 months demonstrating non-inferiority of the high-dose oral therapy. With regards to adverse effects nausea was statistically higher in those in the high dose oral therapy group (11.2% vs 2.5%).  No serious complications were noted.³ This study provides some additional prospective evidence that intravenous therapy may not always be necessary for treatment of MSSA and K. kingae bone and joint infections in children.

 

About the author: Kenna Riley is a Doctor of Pharmacy candidate at the University of Connecticut. This post was written as part of her Advanced Pharmacy Practice Experience under the guidance of her professor, Jennifer Girotto PharmD, BCPPS, BCIDP, who also reviewed and edited the piece.

References

​​1. Woods CR, Bradley JS, Chatterjee A, et al. Clinical practice guideline by the pediatric infectious diseases society (PIDS) and the infectious diseases society of america (IDSA): 2023 guideline on diagnosis and management of acute bacterial arthritis in pediatrics. J Pediatric Infect Dis Soc. 2024;13(1):1–59. doi: 10.1093/jpids/piad089.

​3. Gouveia C, Duarte M, Norte S, et al. Kingella kingae displaced S. aureus as the most common cause of acute septic arthritis in children of all ages. Pediatr Infect Dis J. 2021;40(7):623–627. doi: 10.1097/INF.0000000000003105.

​4. Nielsen AB, Holm M, Lindhard MS, et al. Oral versus intravenous empirical antibiotics in children and adolescents with uncomplicated bone and joint infections: A nationwide, randomised, controlled, non-inferiority trial in denmark. Lancet Child Adolesc Health. 2024;8(9):625–635. doi: 10.1016/S2352-4642(24)00133-0.

​​

 

Influenza Disease and Vaccination

Influenza activity has been increasing for the past few weeks. Centers for Disease Control and Prevention (CDC) influenza surveillance week 50 shows increasing influenza with children especially impacted.  Influenza-like illness last week, was highest in those 0-4 years (11.2%) followed by 5–24-year-olds (7.5%).¹ Emergency department visits for influenza were also significant youth accounting for 9.2% of 5-17 year-old visits and 7% of visits for those 0-4 years-old.¹

Among typed influenza viruses, about 90% are influenza A (H3N2), predominantly the drifted clade 2a.3a.1 subclade K.¹  As you have likely heard, the subclade K is a drifted variant and thus not optimally matched to the H3N2 strain included in the 2025-2026 influenza vaccine.¹ Despite the mismatch, vaccine effectiveness against severe disease and outcomes in pediatrics appears strong. Preliminary data from the United Kingdom suggest that the vaccine has 74.7% (95% CI 52.3 – 87.9) effectiveness against emergency department visits and 72.8% (95% CI 48.3-87.1) effectiveness against hospital admission in children 2-17 years, respectively.²  These findings reinforce the role of influenza vaccination in preventing severe disease in children.

Unfortunately, pediatric influenza vaccination rates are concerningly low with only 40.8% of US children currently vaccinated against influenza.³  Pharmacists play a critical role in educating parents, addressing vaccine hesitance, and reinforcing that vaccination remains important throughout the influenza season.

Key influenza vaccine points to remember^4-6:

• The only way to protect children < 6 months of age is via maternal immunization at least 2 weeks prior to delivery.
• Children 6 months to ≤ 9 years who have not previously received 2 doses of influenza vaccine, require 2 doses this season, separated by ≥ 28 days.
• Other patients should receive 1 dose of influenza vaccine this year.
• Protective immunity takes about 2 weeks (for those needing 2 doses, the 2-week count begins after the second dose).

Influenza Treatment Recommendations

If children become sick with influenza, it is important to ensure they receive guideline recommended treatments.  Data from 2023-2024 US influenza season indicate substantial underutilization of anti-influenza therapy in pediatric patients. Only 31% pediatric outpatients and 52-59% hospitalized pediatric patients with influenza received recommended treatment.⁷ Clinician surveys using pediatric case scenarios highlight gaps in guideline adherence.  In March – June 2024, two surveys (1 outpatient and 1 inpatient) with clinical pediatric influenza cases was sent to prescribers in 7 children’s hospitals and their affiliated community hospitals.^8,9  In the outpatient analysis, clinicians generally only recommended treatment for one of the three recommended cases.⁹ Approximately 50% of inpatient providers recommended therapy for the hospitalized pediatric influenza cases (32% – 59%, depending on the case).⁸  In both studies, pediatric infectious diseases physicians were most likely to choose oseltamivir treatment, with the generalists (e.g., pediatric primary care or hospitalists) least likely.^8,9

Importantly, the CDC reports that anti-influenza treatments (e.g.,  neuraminidase inhibitors, PA Cap-Dependent Endonuclease Inhibitor) continue to be effective against the circulating strains, including H3N2 subclade K.¹  The Infectious Diseases Society of America, American Academy of Pediatrics, and Centers for Disease Control and Prevention all recommend prompt treatment with oseltamivir, regardless of duration of symptoms for all patients with high risk conditions.

Pediatric Patients that are at high risk and should receive treatment with oseltamivir, regardless of duration of symptoms: ^10-12

• All < 2 years of age per CDC ¹¹ or < 5 years of age AAP ¹²;
• All with underlying conditions that increase risk for complications,
• All with severe, complicated, or progressing disease,
• All who are hospitalized with influenza disease.

Consider those with uncomplicated disease who present within 48 hours of symptoms may receive antiviral treatment with any of the neuraminidase inhibitors (i.e., oseltamivir, zanamivir, peramivir) or baloxavir, that are age appropriate (see Table 1).^11,12

Pediatric Specific Outcome Data

Outcome data for anti-influenza treatment in pediatric patients are limited.  Available evidence suggests benefits in prompt treatment of pediatric patients in the outpatient and hospital settings.   Walsh and colleagues evaluated the impact of prompt anti-influenza treatment in pediatric patients hospitalized with influenza.¹³  They included almost 56,000 pediatric patients from multiple centers from 2007 – 2020 in a retrospective analysis.  Those who received prompt oseltamivir within day 0-1 of hospitalization had reduced length of stay, decreased 7-day hospital readmission, and lower risk of ECMO use/death compared to those who received delayed or no oseltamivir treatment.¹³ In the outpatient setting, an individual patient meta-analysis was performed including 5 trials and 2,561 pediatric patients who were randomized to receive oseltamivir or placebo within 48 hours of symptom onset.¹⁴  Oseltamivir reduced symptom duration by 17.6 hours (0.7 – 34.5 hours) and had a 34% risk reduction in acute otitis media infections. An increase in vomiting was found in those that received oseltamivir (RR 1.63 (95% CI 1.3-2.04).¹⁴

Pharmacists Role

With the increasing influenza disease activity, pharmacists have an essential role to ensure parents understand the importance and effectiveness of the influenza vaccination.  In addition, cases of clinical influenza disease provides an antimicrobial stewardship opportunity to recommend appropriate anti-influenza therapy in high-risk pediatric patients.

 

Table 1.  Anti-Influenza Medications for Treatment of Influenza Disease^11,15

Medication	FDA approval ages for treatment	Notes
Oseltamivir (Tamiflu®)	≥ 14 days-old (any age)	Intermittent shortage reported for some manufacturers as of Dec 2025
Zanamivir (Relenza®)	≥ 7 years-old	Do not use in those with respiratory disease or lactose/milk protein allergy
Peramivir (Rapivab™)	≥ 6 months-old
Baloxavir (Xofluza®)	≥ 5 years	Do not crush tablets, instead use suspension packets in those < 20 kg or who cannot take tablets. Not recommended as monotherapy for immunocompromised

References

1. Centers for Disease Control and Prevention. FluView:Weekly US Influenza Surveillance Report. Accessed December 23, 2025https://www.cdc.gov/fluview/surveillance
2. Kirsebom FC, Thompson C, Talts T, et al. Early influenza virus characterisation and vaccine effectiveness in England in autumn 2025, a period dominated by influenza A(H3N2) subclade K. Euro Surveill. 2025;30(46):2500854. doi: 10.2807/1560
3. Centers for Disease Control and Prevention. FluVaxView. Accessed Deccember 23, 2025. Available at: https://www.cdc.gov/fluvaxview/dashboard/vaccine-doses-distributed.html
4. American Academy of Pediatrics, Committee on Infectious Diseases. Red Book : Report of the Committee on Infectious Diseases 2024 – 2027. AAP Immunization Schedule. Accessed December 12, 2025. Available at: https://publications.aap.org/redbook/resources/15585/AAP-Immunization-Schedule
5. American Academy of Family Physicians. Immunization Schedules. Accessed December 12, 2025. Available at: https://www.aafp.org/family-physician/patient-care/prevention-wellness/immunizations-vaccines/immunization-schedules.html
6. Centers for Disease Control and Prevention. Child and Adolescent Immunization Schedule by Age (Addendum updated August 7, 2025). Accessed September 20, 2025. Available at: https://www.cdc.gov/vaccines/hcp/imz-schedules/child-adolescent-age.html
7. Frutos AM, Ahmad HM, Ujamaa D, et al. Underutilization of Influenza Antiviral Treatment Among Children and Adolescents at Higher Risk for Influenza-Associated Complications – United States, 2023-2024. MMWR Morb Mortal Wkly Rep. 2024;73(45):1022–1029
8. Bassett HK, Rao S, Beck J, et al. Variability of Clinician Recommendations for Oseltamivir in Children Hospitalized with Influenza. Pediatrics. 2025;155(5):e2024069111. doi: 10.1542/peds.2024–069111
9. Bassett HK, Rao S, Beck J, et al. Clinician Preferences for Oseltamivir Use in Children With Influenza in the Outpatient Setting. Pediatrics. 2025;156(3):e2025071193. doi: 10.1542/peds.2025–071193
10. Uyeki TM, Bernstein HH, Bradley JS, et al. Clinical Practice Guidelines by the Infectious Diseases Society of America: 2018 Update on Diagnosis, Treatment, Chemoprophylaxis, and Institutional Outbreak Management of Seasonal Influenza. Clin Infect Dis. 2019;68(6):895–902
11. Centers for Disease Control and Prevention. Influenza Antiviral Medications: Summary for Clinicians. Accessed December 23, 2025. Available at: https://www.cdc.gov/flu/hcp/antivirals/summary-clinicians.html
12. Committee on Infectious Diseases. Recommendations for Prevention and Control of Influenza in Children, 2025-2026: Policy Statement. Pediatrics. 2025;156(6):e2025073620. doi: 10.1542/peds.2025–073620
13. Walsh PS, Schnadower D, Zhang Y, et al. Association of Early Oseltamivir with Improved Outcomes in Hospitalized Children with Influenza, 2007-2020. JAMA Pediatr. 2022;176(11):e223261
14. Malosh RE, Martin ET, Heikkinen T, et al. Efficacy and Safety of Oseltamivir in Children: Systematic Review and Individual Patient Data Meta-analysis of Randomized Controlled Trials. Clin Infect Dis. 2018;66(10):1492–1500
15. Michelle Wheeler. ASHP Drug Shortages – Current Shortages. Accessed December 23, 2025. Available at: https://www.ashp.org/drug-shortages/current-shortages/drug-shortage-detail.aspx?id=881&loginreturnUrl=SSOCheckOnly

 

By Marissa Galicia, PharmD candidate

Multidrug-resistant organisms (MDROs) represent a threat to global health, causing infections that are difficult to treat due to resistance to multiple antimicrobial classes. Some preventable ways that MDROs develop are when antibiotics are used longer than necessary or taken inappropriately.¹ Initially, only a few bacteria may survive antibiotic treatment, but frequent or inappropriate use increases the likelihood of resistant bacteria surviving and causing infections. Rising resistance rates, emphasizing the urgency of optimizing treatment strategies for pediatric populations.¹

Antibiotic Susceptibility in Children’s Hospitals Across the United States

In a 2025, Markham and colleagues published a multicenter analysis of antibiograms from 46 U.S. children’s hospitals.²   Most isolates in these hospitals remained susceptible with about 65% of Staphylococcus aureus was methicillin susceptible and 80% susceptible to clindamycin. Among Gram-negative bacteria, there was high susceptibility to cefazolin.²  For Gram-negatives greater than 85% E. coli and 78% Klebsiella sp. were susceptible to cefazolin.  Although many of these isolates were susceptible, resistance does sometimes occur.  Thirty-five percent of Staphylococcus aureus isolates and 57% of coagulase negative staphylococcus were resistant to oxacillin.   Almost 6% of E. coli, 9% of Klebsiella sp., and 17% of Serratia sp. resistant to ceftriaxone [possibly a signal for a possible extended spectrum beta-lactamase (ESBL) producer or other multidrug resistance (MDR) mechanism].  Enterobacter is generally thought to be resistant to ceftriaxone, regardless of the reporting, but in this study almost 6% were also resistant to ertapenem.  Cefepime, meropenem, and piperacillin-tazobactam, common anti-pseudomonas therapies each were reported to have about 10% pseudomonal resistance.  Lastly, and a bit concerningly 17% of Acinetobacter sp. were listed with meropenem resistance.²

In recent years, the Infectious Diseases Society of America has published recommendations for treatment of MDR infections.³  This includes the treatment of some important Gram-negative resistances such as Carbapenem-resistant Enterobacterales (CRE), Carbapenem-resistant Acinetobacter, Extended-spectrum beta-lactamase-producing Enterobacterales (ESBL-E), and multidrug-resistant (MDR) Pseudomonas aeruginosa.  As a pharmacist, it is essential to consider the significant differences that often exist in pediatric and adult pharmacokinetics (e.g., increased distribution, increased clearance) these can impact on likelihood of attaining pharmacodynamic targets.⁴,  Thus the dose becomes as important as the choice of agents. A group that included pediatric infectious diseases physician and pharmacist experts published consensus recommendations for the dosing of select beta-lactam agents used to treat these antimicrobial-resistant Gram-negative infections in children.⁵ This review focuses on the treatment of these MDROs, which may be uncommon, but important infections in pediatrics (with dosing considerations for older children and adults).

Types of Resistance Impacting Enterobacterales

ESBLs enzymes inactivate most penicillins, cephalosporins, and aztreonam. When present, they are most frequently seen in Escherichia coli, Klebsiella pneumoniae, Klebsiella oxytoca, and Proteus mirabilis.³  AmpC enzymes are primarily involved in cell wall recycling they can hydrolyze many beta-lactam agents. Enterobacter cloacae complex, Klebsiella aerogenes, and Citrobacter freundii are most at risk for inducing AmpC production. IDSA Guidance document suggests that resistance to common beta-lactams (e.g., ceftriaxone, piperacillin-tazobactam) develops in 20% of infections caused by these agents.³ Carbapenem Resistant Enterobacterales (CRE) are another significant MDRO which can be caused by carabapenemases (CP-CRE; e.g., KPC, NDM, OXA-48, VIM, and IMP) or can be caused by non-enzyme mechanisms such as altered membrane porins and overproduction of AmpC or ESBL enzymes (CRE).^3,6

The IDSA recommends the following treatments when an ESBL, AmpC, CRE, and CP-CRE are identified below. Note dosing will be provided with the first instance and can be assumed to be the same throughout unless otherwise stated.

Uncomplicated cystitis caused by ESBL, AmpC, CRE, CP-CRE: ^3,7,8

First line recommendations:

• Oral nitrofurantoin (< 12 years: 1.25 – 1.75 mg/kg/dose 4 times a day; max 100mg/dose; ≥12 years: Macrobid 100 mg twice daily) or
• Oral sulfamethoxazole/trimethoprim (3 to 6 mg/kg/dose (trimethoprim component) PO twice daily; max 320 mg/dose).

Alternatives: all oral: ciprofloxacin (15mg/kg/dose twice daily; max 500mg/dose), levofloxacin (< 50 kg: 8 mg/kg/dose twice daily; max 500 mg/day, ≥ 50 kg: 500 mg once daily), or carbapenems.

Complicated urinary tract infections (e.g., pyelonephritis) caused by ESBL, AmpC, CRE, CP-CRE: ^3,5,9-12

First-line recommendations:

• For AmpC, ESBL, or CRE/CP-CRE: Sulfamethoxazole/trimethoprim or fluroquinolones are considered first line if susceptible.
• For CRE/CP-CRE: ceftazidime-avibactam (50 mg/kg/dose Q8h over 3 hours; max 2g/dose), meropenem-vaborbactam (40 mg/kg/dose Q8h over 3 hours; max 2 g/dose), imipenem-cilastain-relebactam (25 mg/kg/dose Q6h; max 1 g/dose), or cefiderocol (60 mg/kg/dose Q8h over 3 hours; max 2g/dose) are other first-line options.

Alternatives:

• For AmpC, ESBL, or CRE/CP-CRE: aminoglycoside (e.g., gentamicin – dosing depending on patient age)
• For ESBLs: carbapenems [e.g., meropenem (20mg/kg/dose q8h; max 2,000 mg/dose) or ertapenem (<13 years: 15mg/kg/dose q12h, max 1000 mg/day; ≥13 years: 1000 mg/day once daily)]

 For all other systemic infections caused by AmpC, ESBL, or CRE/CP-CRE:³

First-line recommendations: ^3,9,11

• AmpC: Cefepime dosing dependent on MIC, fully susceptible (i.e., MICs < 2 mg/L) 50 mg/kg/dose Q12h as 3-hour infusion or 50 mg/kg/dose Q8h as traditional 0.5 hour infusion can be used. For those with susceptible dose dependent organisms (e.g., MIC 4-8 mg/L) the 50 mg/kg/dose Q8h as a 3-hour infusion may be needed.
• ESBL and some CRE: Carbapenems, are recommended first-line for ESBL until the patient is well enough to transition to oral therapy (ertapenem is cautioned in critically ill or malnourished). In cases of CRE when only ertapenem is resistant, meropenem is susceptible (i.e., MIC < 1 mg/L) meropenem can be used at high dose-prolonged infusion (e.g., 40 mg/kg/dose Q8h over 3 hours).
• AmpC and ESBL(improving): Guidance suggests considering either sulfamethoxazole/ trimethoprim or fluoroquinolone, when the patient is well enough to transition to oral therapy and it is susceptible to the agent.
• CRE/CP-CRE: Patients with organisms that demonstrate resistance to carbapenems beyond ertapenem are recommended to receive ceftazidime-avibactam, meropenem-vaborbactam, or imipenem-cilastain-relebactam.

Carbapenem-resistant Acinetobacter baumannii (CRAB)

Acinetobacter baumannii (A. Baumannii) is a major pathogen of significance that has demonstrated mortality rates in adults between 26-56%. ¹³  Firstline treatment recommendations include sulbactam-durlobactam with either imipenem-cilastin or meropenem. Limited data exists on sulbactam-durlobactam in pediatrics.  Based upon extrapolation and a population-pharmacokinetic model study, estimates suggest dose of 50 mg/kg/dose sulbactam Q6h (max 1g of each component/dose) and infused over 3-4 hours may be reasonable in cases of life-threatening A. baumannii infection.^3,14.

Difficult-to-Treat Resistant (DTR) Pseudomonas aeruginosa

Difficult to treat P. aeruginosa is defined by non-susceptibility to at least one antibiotic in three classes commonly active against P. aeruginosa. Preferred treatments include high-dose extended infusion of non-carbapenem beta-lactams for susceptible strains. For resistant strains, ceftolozane-tazobactam (30mg/kg q8h; max 1.5g/dose), ceftazidime-avibactam, or imipenem-cilastin-relebactam may be necessary.³

Stenotrophomonas maltophilia

Stenotrophomonas maltophilia (S. maltophilia) is a glucose non-fermenting gram-negative bacillus that produces metallo-beta-lactamases leading to resistance of many antibiotics. Decisions to provide targeted therapy for S. maltophilia are difficult as it is can sometimes be a colonizer and frequently identified within polymicrobial infections. Further, data comparing the effectiveness of commonly used agents for S. maltophilia are lacking. IDSA guidance recommended treatment includes any two of the following options: cefiderocol, sulfamethoxazole/ trimethoprim, levofloxacin, ceftazidime-avibactam in combination with aztreonam (30 mg/kg/dose 4 times daily; max 2000 mg/day) another one of the options would be minocycline (2 mg/kg/dose twice daily; max 100mg/dose – see pediatric considerations below).

Pediatric Specific Considerations:

In addition to dosing, there are other important considerations that should be considered when using antibiotics for pediatric patients with MDROs.

• Sulfamethoxazole/ trimethoprim is not generally recommended in children < 2 months; however it has been used in neonates in rare cases when the benefits outweigh the risks.^15-18
• Fluoroquinolones should only be used in pediatric patients when there is no other alternative or the only other option is parenteral therapy, this is because of significant adverse effects including tendinitis and tendon rupture, peripheral neuropathy, and central nervous system effects (e.g., dizziness, restlessness, confusion, and insomnia to toxic psychosis).^{19-21 .}
• Minocycline as a traditional tetracycline, is generally not recommended in pediatric patients less than 8 years of age due to teeth staining^8.

 

Table 1.  Summary of Treatment Recommendations

Resistant Organism	Preferred Therapy
Systemic Infection Caused by ESBL-producing Enterobacterales	Carbapenem
Systemic Infection Caused by AmpC-producing Enterobacterales	Cefepime, when able to transition to oral: sulfamethoxazole/trimethoprim or fluoroquinolone
CRE	If non CP-CRE, and only resistant to ertapenem: high dose extended infusion meropenem. CP-CRE: ceftazidime-avibactam, meropenem-vaborbactam, or imipenem-cilastain-relebactam
DTR Pseudomonas aeruginosa	Ceftolozane-tazobactam, ceftazidime-avibactam, or imipenem-cilastin-relebactam
CRAB (Acinetobacter baumannii)	Sulbactam-durlobactam + carbapenem (imipenem-cilastin or meropenem)
Stenotrophomonas maltophilia	Any 2 of the Following: cefiderocol, sulfamethoxazole/ trimethoprim, levofloxacin, minocycline, or ceftazidime-avibactam plus aztreonam

 

About the author: Marissa Galicia is a Doctor of Pharmacy candidate at the University of Connecticut. This post was written as part of her Advanced Pharmacy Practice Experience under the guidance of her professor, Jennifer Girotto PharmD, BCPPS, BCIDP, who also reviewed and edited the piece.

 

 

References

1. Centers for Disease Control and Prevention. Antimicrobial Resistant Threats in the United States 2021-2022. Accessed July 9, 2025https://www.cdc.gov/antimicrobial-resistance/data-research/threats/update-2022.html#:~:text=Findings,-resistant%20(MDR)%20Pseudomonas%20aeruginosa
2. Markham JL, Hall M, Burns A, et al. Antibiotic susceptibility patterns in US children’s hospitals. J Hosp Med. 2025
3. Tamma PD, Heil EL, Justo JA, et al. Infectious Diseases Society of America 2024 Guidance on the Treatment of Antimicrobial-Resistant Gram-Negative Infections. Clin Infect Dis. 2024
4. Batchelor HK, Marriott JF. Paediatric pharmacokinetics: key considerations. Br J Clin Pharmacol. 2015;79(3):395–404
5. Lockowitz CR, Hsu AJ, Chiotos K, et al. Suggested Dosing of Select Beta-lactam Agents for the Treatment of Antimicrobial-Resistant Gram-Negative Infections in Children. J Pediatric Infect Dis Soc. 2025;14(2):piaf004
6. Suay-García B, Pérez-Gracia MT. Present and Future of Carbapenem-resistant Enterobacteriaceae (CRE) Infections. Antibiotics (Basel). 2019;8(3):122. doi: 10.3390/antibiotics8030122
7. Subcommittee on Urinary Tract Infection, Steering Committee on Quality Improvement and Management, Roberts KB. Urinary tract infection: clinical practice guideline for the diagnosis and management of the initial UTI in febrile infants and children 2 to 24 months. Pediatrics. 2011;128(3):595–610
8. Kimberlin DW, Banerjee R, Barnett E, Lynfield R, Sawyer MH. Red book: 2024-2027 Report of the Committee on Infectious Diseases American Academy of Pediatrics. Thirty-third edition. ed. American Academy of Pediatrics. Committee on Infectious Diseases, author.; American Academy of Pediatrics; 2024
9. Clinical and Laboratory Standards Institute. M100-ED35:2025 Performance Standards for Antimicrobial Susceptibility Testing. 35th ed. ; 2025
10. Ertapenem Product Information. Accessed Dec 3, 2025 https://www.accessdata.fda.gov/drugsatfda_docs/label/2022/021337s051lbl.pdf
11. Courter JD, Kuti JL, Girotto JE, Nicolau DP. Optimizing bactericidal exposure for beta-lactams using prolonged and continuous infusions in the pediatric population. Pediatr Blood Cancer. 2009;53(3):379–385
12. Bradley JS, Orchiston E, Portsmouth S, et al. Pharmacokinetics, Safety and Tolerability of Single-dose or Multiple-dose Cefiderocol in Hospitalized Pediatric Patients Three Months to Less Than Eighteen Years Old With Infections Treated With Standard-of-care Antibiotics in the PEDI-CEFI Phase 2 Study. Pediatr Infect Dis J. 2025;44(2). https://journals.lww.com/pidj/fulltext/2025/02000/pharmacokinetics,_safety_and_tolerability_of.9.aspx
13. Appaneal HJ, Lopes VV, LaPlante KL, Caffrey AR. Treatment, Clinical Outcomes, and Predictors of Mortality among a National Cohort of Admitted Patients with Acinetobacter baumannii Infection. 2022;66(3):1975
14. Onita T, Sano Y, Ikawa K, et al. Population Pharmacokinetic Analysis and Pharmacodynamic Evaluation of Sulbactam in Pediatric Patients: Dosing Suggestions for Acinetobacter baumannii Infections. J Pediatric Infect Dis Soc. 2025;14(5):piaf043. doi: 10.1093/jpids/piaf043
15. Ryan KL, Dersch-Mills D, Clark D. Trimethoprim-Sulfamethoxazole for Treatment of Stenotrophomonas maltophilia Pneumonia in a Neonate. Can J Hosp Pharm. 2013;66(6):384–387
16. Bang AT, Reddy HM, Deshmukh MD, et al. Neonatal and infant mortality in the ten years (1993 to 2003) of the Gadchiroli field trial: effect of home-based neonatal care. J Perinatol. 2005;25 Suppl 1:92
17. Bang AT, Bang RA, Baitule SB, et al. Effect of home-based neonatal care and management of sepsis on neonatal mortality: field trial in rural India. Lancet. 1999;354(9194):1955–1961
18. Bhutta ZA, Zaidi AKM, Thaver D, et al. Management of newborn infections in primary care settings: a review of the evidence and implications for policy? Pediatr Infect Dis J. 2009;28(1 Suppl):22
19. Jackson MA, Schutze GE, COMMITTEE ON INFECTIOUS DISEASES. The Use of Systemic and Topical Fluoroquinolones. Pediatrics. 2016;138(5):e20162706
20. Muradian M, Khan S. Levofloxacin-induced Psychosis in a Young Healthy Patient. Cureus. 2019;11(11):e6217
21. Tandan M, Cormican M, Vellinga A. Adverse events of fluoroquinolones vs. other antimicrobials prescribed in primary care: A systematic review and meta-analysis of randomized controlled trials. Int J Antimicrob Agents. 2018;52(5):529–540

 

By Sydney E. Kolosky, PharmD candidate

Neonatal late-onset sepsis is a systemic infection that is acquired from the hospital environment after 72 hours of life.¹ It represents a major cause of morbidity and mortality among neonates, particularly those born very preterm, with an incidence of 9% which results in approximately 11% lower risk of survival.² Unfortunately, despite improved infection prevention efforts, this decreased survival rate across all gestational ages remains.² The increase in mortality among the most preterm infants is, at least in part, one driver of antimicrobial usage in this population. Currently, there is an absence of specific recommendations guiding empirical antibiotic selection for treatment of late-onset sepsis in neonates due to variability in pathogens and local susceptibility.

The study Late Antibiotic Use Among Preterm Infants Admitted to the Neonatal Intensive Care Unit, published in 2025 by Coggins and colleagues, touches upon the impact of the variability for antibiotic selection in neonates with late-onset sepsis. It investigated antibiotic use among 420,000 infants from 2009-2023 to describe contemporary antibiotic patterns in preterm infants with late-onset neonatal sepsis.³ The study found that the use of antibiotics for late-onset sepsis was inversely proportional to the gestational age group with antibiotics being administered to 75% of infants born 22 to 24 week’s gestational age compared to about 4% of infants born 33 to 34 week’s gestational age.³ The Coggins study inspired this review, which will summarize the current United States epidemiology, causative pathogens, and antibiotic use trends to improve understanding and treatment of late-onset sepsis in neonates.

Causative Pathogens

Two articles from 2022 offer updated evidence regarding current pathogens driving neonatal late-onset sepsis in the United States. In 2022, the study Late-Onset Sepsis Among Very Preterm Infants, by Flannery and colleagues using the Vermont Oxford Network data, identified Gram-positive bacteria as the predominant pathogens accounting for 63% of isolates (29% coagulase-negative staphylococci, 23% Staphylococcus aureus, 5% Enterococcus spp., 5% Group B Streptococcus)²  The two most common Gram-negative bacteria identified included Escherichia coli (12%) and Klebsiella spp. (8%).² The review article Updates in Late-Onset Sepsis: Risk Assessment, Therapy, and Outcomes also reported that neonatal late-onset sepsis is primarily driven by Gram-positive bacteria, with coagulase-negative staphylococci isolated in more than half of gram-positive bacteremia among preterm infants.⁴ Although these data capture a broader picture of common causative pathogens in NICUs throughout the United States. Variation in pathogen patterns and susceptibility data across different geographic regions still exists and should be considered when selecting appropriate empiric treatment.

New Insights on Antibiotic Utilization in Late-Onset Neonatal Sepsis

To identify possible opportunities for antimicrobial stewardship, the 2025 study by Coggins and colleagues described recent trends in antibiotic utilization for late onset sepsis in the United States. The study found vancomycin and gentamicin was the most common regimen, representing 19% of all courses of antibiotics given after the first 72 hours of life, followed by ampicillin plus gentamicin (12%) and cefazolin (8%).³ Alternative regimens that contained gram-negative agents beyond gentamicin include cefotaxime and vancomycin (4%), tobramycin and vancomycin (4%), cefepime and vancomycin (3%), piperacillin/tazobactam (2%), ceftazidime and vancomycin (2%), amikacin and vancomycin (2%), cefepime (1%), meropenem and vancomycin (1%).³ Susceptibility data varies across geographic regions leading to certain antibiotics being resistant in specific areas of the country while others are susceptible in other areas. Ultimately, this susceptibility plays a major role in the choice of antibiotics and leads to variations in antibiotic regimens for this disease state.

In addition to studying the trends across combination antibiotic regimens, the study also looked at the individual components of the regimens. Vancomycin was the most common individual component (45%) in the antibiotic regimens, however, the use of vancomycin-containing regimens remarkably declined from 58.8% of all courses in 2009 to 36.0% in 2023 (P < .001).³ The decline of vancomycin occurred at the same time there were increases of prescriptions for antistaphylococcal penicillins (i.e., nafcillin, oxacillin [7% to 18%, P < .001]), piperacillin/tazobactam (3% to 9%, P < .001), and cefepime (2% to 12%, P < .001).³ Additionally, antibiotic choice notably changed over the course of NICU care with cefazolin becoming the main antibiotic exposed to the neonate after 90 days of age.³ The increased utilization of cefazolin suggests its use for surgical site infection prophylaxis in these older infants.

This study contributes new insights to late-onset neonatal sepsis in two important ways. First, it quantifies how antibiotic use in late-onset sepsis has shifted across the United States, illustrating changing stewardship priorities to reduce the use of broad-spectrum antibiotics in the neonatal population, particularly those with methicillin-resistant S. aureus (MRSA) coverage. Secondly, it demonstrates how significant variability exists in practice despite the availability of national guidance, underscoring the need for standardized empiric treatment frameworks that align with current microbiology, local resistance data, and American Academy of Pediatrics (AAP) recommendations.

Antibiotic Treatment Patterns in the United States

MRSA infections have been found to be less common in comparison to methicillin-susceptible S. aureus (MSSA) infections in late-onset sepsis.² In the neonatal population, S. aureus infections (either MRSA or MSSA) develop after the neonate is colonized with the bacteria. Colonization of MRSA in the NICU has been a focus of infection prevention and control initiatives, particularly those aimed at developing strategies and recommendations to de-colonize infants to prevent infection. The Centers for Disease Control and Prevention (CDC) and Society for Healthcare Epidemiology of America (SHEA) advocate for routine active surveillance of S. aureus, including MSSA and MRSA, especially in neonates with low birth weight who are at higher risk for infection.⁵ This strategy allows NICUs to determine the baseline S. aureus colonization status of a neonate. If a neonate is determined to be colonized with either MSSA or MRSA, SHEA suggests that intranasal mupirocin twice daily for 5-7 days for decolonization in the NICU population.⁵

The empiric treatment for late-onset sepsis can be tailored to the neonate based on their baseline S. aureus colonization status. The 2022 study Safety and Efficacy of Nafcillin for Empiric Therapy of Late-Onset Sepsis in the NICU by Nationwide Children’s Hospital concluded nafcillin is a safe alternative to vancomycin for empiric therapy in neonates with late-onset sepsis not colonized by MRSA as there was no difference in mortality.⁶ This is despite many infections being caused by coagulase-negative staphylococcus. It is also consistent with the AAP Red Book recommendation for MSSA infections, where nafcillin or oxacillin are recommended as preferred agents, especially when there is a risk for meningitis as cefazolin may not have optimal cerebrospinal fluid concentrations.⁷ For sepsis caused by MRSA, vancomycin remains the preferred agent.⁷

Gram-negative infections are less common than Gram-positive infections, accounting for roughly a quarter of neonatal late-onset sepsis infections.² The prevalence of these infections underscores the need for effective antimicrobial therapy targeting key Gram-negative pathogens, such as Escherichia coli and Klebsiella spp. For neonatal sepsis with suspected or confirmed infection by Enterobacterales or Group B Streptococci, the AAP Red Book recommends that ampicillin and an aminoglycoside be considered as first-line therapy.^8-10 Typically, gentamicin is the aminoglycoside of choice for neonates who have infections without central nervous system involvement.¹⁰

The 2023 study Antibiotic Use Among Infants Admitted to Neonatal Intensive Care Units, by Flannery and colleagues, concluded that gentamicin follows vancomycin as the second most prevalent empiric antimicrobial agent at 48% compared to 51%, respectively.¹¹ However, new data suggests that resistance to gentamicin is increasing with 7% of E. coli neonatal late-onset sepsis cases being gentamicin resistant.¹² If resistance precludes use of gentamicin, the AAP Red Book recommends replacement with ceftazidime, cefepime, amikacin, or a carbapenem.^9,10 The role of pharmacists is critical in this context to ensure individual institutions choose empiric therapy options that both cover isolates seen in their units and penetrate effectively to the source of infection, while also utilizing traditional stewardship efforts to guide clinicians towards the narrowest agents expected to cover the organisms of concern.

The duration of treatment is of equal importance to the selection of the empiric therapy itself and is another area of opportunity for antimicrobial stewardship. Although there are not any consensus guidelines in the United States, the National Institute for Health and Care Excellence (NICE) in the United Kingdom recommends an antibiotic treatment duration of 7 days in neonates with late-onset sepsis who have a positive blood culture, keeping in mind that causative organisms and source may also influence the duration.¹³ Additionally, NICE recommends that antibiotics be discontinued before 48 hours if the neonate has a negative blood culture and thought to no longer have an infectious cause.¹³ Recent data from Speier and colleagues found that the median antibiotic treatment durations for late-onset sepsis was 4 days for a culture-negative evaluation and 12 days for a culture-positive episode.¹⁴ The longer duration of treatment in both groups emphasizes the need for Antimicrobial Stewardship Program (ASP) targets to help ensure prompt discontinuation of antibiotics when treatment is no longer required to minimize antibiotic exposure and resistance development.

Conclusion

Neonatal late-onset sepsis remains a strong area of focus for ASP focus given the increased morbidity, mortality, and antibiotic exposure among neonates. While there is commonality in the antibiotics used to treat this condition based on predominant pathogens, treatment patterns still vary widely across the country. Recent shifts in antibiotic utilization reflect progress towards more targeted therapy informed by causative pathogens, local susceptibility data, and resistance trends, making this an important area for continued stewardship intervention. These findings also highlight the critical role pharmacists can play in guiding empiric antibiotic selection that incorporates local susceptibility data and assists in discussions regarding duration to limit excessive antibiotic exposure. Overall, continued efforts to standardize treatment practices and minimize unnecessary antibiotic exposure in the neonatal population are essential to improving ASP in this disease state.

 

Empiric Treatment Considerations*
No History of MRSA Colonization or Infection	nafcillin or oxacillin PLUS gentamicin, an extended-spectrum cephalosporin (e.g., ceftazidime, cefepime), amikacin, or a carbapenem
MRSA Colonization and/or History of MRSA Infection	vancomycin PLUS gentamicin, an extended-spectrum cephalosporin (e.g., ceftazidime, cefepime), amikacin, or a carbapenem

*Consider local susceptibility data when developing initial empiric antibiotic therapy plans.

 

About the author: Sydney E. Kolosky is a Doctor of Pharmacy candidate at the University of Connecticut. This post was written as part of her Advanced Pharmacy Practice Experience under the guidance of her professor, Jennifer Girotto PharmD, BCPPS, BCIDP, who also reviewed and edited the piece.

References

1. Glaser MA, Hughes LM, Jnah A, Newberry D. Neonatal sepsis: A review of pathophysiology and current management strategies. Adv Neonatal Care. 2021;21(1):49–60. doi: 10.1097/ANC.0000000000000769.
2. Flannery DD, Edwards EM, Coggins SA, Horbar JD, Puopolo KM. Late-onset sepsis among very preterm infants. Pediatrics. 2022;150(6):e2022058813. doi: 10.1542/peds.2022–058813. doi: 10.1542/peds.2022-058813.
3. Coggins SA, Zevallos Barboza A, Puopolo KM, Flannery DD. Late antibiotic use among preterm infants admitted to the neonatal intensive care unit. Pediatrics. 2025;156(5):e2025071372. doi: 10.1542/peds.2025–071372. doi: 10.1542/peds.2025-071372.
4. Coggins SA, Glaser K. Updates in late-onset sepsis: Risk assessment, therapy, and outcomes. Neoreviews. 2022;23(11):738–755. doi: 10.1542/neo.23-10-e738.
5. Akinboyo IC, Zangwill KM, Berg WM, Cantey JB, Huizinga B, Milstone AM. SHEA neonatal intensive care unit (NICU) white paper series: Practical approaches to staphylococcus aureus disease prevention. Infect Control Hosp Epidemiol. 2020;41(11):1251–1257. doi: 10.1017/ice.2020.51.
6. Magers J, Prusakov P, Speaks S, Conroy S, Sánchez PJ. Safety and efficacy of nafcillin for empiric therapy of late-onset sepsis in the NICU. Pediatrics. 2022;149(5):e2021052360. doi: 10.1542/peds.2021–052360. doi: 10.1542/peds.2021-052360.
7. Staphylococcus aureusCommittee on Infectious Diseases, American Academy of Pediatrics, Kimberlin DW, Banerjee R, Barnett ED, Lynfield R, Sawyer MH, eds. Red book: 2024–2027 report of the committee on infectious diseases. American Academy of Pediatrics; 2024:0. https://doi.org/10.1542/9781610027373-S3_018_008. 10.1542/9781610027373-S3_018_008.
8. Puopolo KM, Lynfield R, Cummings JJ, et al. Management of infants at risk for group B streptococcal disease. Pediatrics. 2019;144(2):e20191881. https://doi.org/10.1542/peds.2019-1881. Accessed 11/14/2025. doi: 10.1542/peds.2019-1881.
9. Group B streptococcal infectionsCommittee on Infectious Diseases, American Academy of Pediatrics, Kimberlin DW, Banerjee R, Barnett ED, Lynfield R, Sawyer MH, eds. Red book: 2024–2027 report of the committee on infectious diseases. American Academy of Pediatrics; 2024:0. https://doi.org/10.1542/9781610027373-S3_018_011. Accessed 11/14/2025. 10.1542/9781610027373-S3_018_011.
10. Serious neonatal bacterial infections caused by enterobacterales (including septicemia and meningitis)Committee on Infectious Diseases, American Academy of Pediatrics, Kimberlin DW, Banerjee R, Barnett ED, Lynfield R, Sawyer MH, eds. Red book: 2024–2027 report of the committee on infectious diseases. American Academy of Pediatrics; 2024:0. https://doi.org/10.1542/9781610027373-S3_005_002. Accessed 11/20/2025. 10.1542/9781610027373-S3_005_002.
11. Flannery DD, Zevallos Barboza A, Mukhopadhyay S, et al. Antibiotic use among infants admitted to neonatal intensive care units. JAMA Pediatr. 2023;177(12):1354–1356. https://doi.org/10.1001/jamapediatrics.2023.3664. Accessed 11/14/2025. doi: 10.1001/jamapediatrics.2023.3664.
12. Hoffman A, Satyavolu S, Muhanna D, et al. Predictors of mortality and severe illness from escherichia coli sepsis in neonates. J Perinatol. 2024;44(12):1816–1821. doi: 10.1038/s41372-024-02117-9.
13. National Institute for Health and Care Excellence (NICE). Neonatal infection: Antibiotics for prevention and treatment. 2024.
14. Speier RL, Cotten CM, Benjamin DKJ, et al. Late-onset sepsis evaluation and empiric therapy in extremely low gestational age newborns. J Pediatric Infect Dis Soc. 2023;12(Supplement_2):S37–S43. doi: 10.1093/jpids/piad068.

It is Antibiotic Awareness week! It is a great time to renew our understandings and efforts regarding appropriate use of antibiotics, as inappropriate usage can lead to unnecessary resistance and adverse effects.  For 2025, the CDC’s theme is “Fighting Antimicrobial Resistance Takes All of Us”.

There are two easy ways we as pharmacists can help improve antibiotic usage for our youngest patients. 

• ️The first is to recommend/provide immunizations to help prevent the children from getting significant illnesses.
  1. Recommend/provide routine and seasonal childhood immunizations.
  2. In the fall, provide additional education to parents regarding seasonal immunizations that are appropriate for the infant/child’s age (e.g., RSV mab, influenza vaccine, COVID-vaccine)
• ‍‍Educate parents about what infections are most likely caused by viruses versus bacteria. When the kids are sick, it is good to explain to the parents that the best care for respiratory viruses (other than flu and COVID-19) is supportive management. The CDC has a nice summary here.  This often includes hydration and targeted symptom management with things such as antipyretics, honey (if > 12 months), and nasal saline.  It is important to educate parents that antibiotics will not help treat viral infections.  Explaining that by not using the antibiotics when they will not help, they will help save the antibiotics for the conditions when they are needed (e.g., group A streptococcal pharyngitis, otitis media in some cases).

 

As mentioned above, Flu and COVID-19 are two viral conditions that have specific treatments.  These treatments are reserved for those with severe disease or at high risk for severe disease.  For flu this includes all children who are less than 2-5 years old with oseltamivir.  While COVID-19 treatment recommendations are provided by the Infectious Diseases Society of America.

 

For more resources Go Purple and visit the USAAW Resources: https://www.cdc.gov/antimicrobial-resistance/communication-resources/usaaw.html

 

A recent article by Kaplan and colleagues was published in the Journal of Pediatric Infectious Diseases in November 2025 evaluating the pneumococcal serotypes and susceptibility of invasive pneumococcal disease in children.¹ In this article, the authors evaluated pediatric pneumococcal disease in children admitted to 8 hospitals across the United States from 2018 – 2023. These findings help us identify information on which pneumococcal diseases continue to occur despite vaccination, inform current empiric treatment strategies in children and help identify areas for targeted stewardship interventions.

Pneumococcal Disease and Conjugate Vaccine History

To fully understand this article, it is essential to understand the history of the pneumococcal disease and vaccination. Pneumococcal disease has significantly cased invasive infections in young and old as well as those with significant chronic conditions including immunocompromise. The incidence of these infections has been greatly reduced from ~ 25 per 100,000 in late 1990’s to < 10 per 100,000 in 2023.² This reduction has been primarily due to pneumococcal vaccination. In 2010, the pneumococcal conjugate 13 valent vaccine (PCV13) replaced the 7 valent vaccine (PCV7). A key advantage of this broadening was the coverage of serotype 19A, which was a major cause of severe, antibiotic resistant infections in young children.³ More recently, the 15 and 20 valent pneumococcal vaccines (PCV15, PCV20) were recommended for use in children in 2022 and 2023, respectively.^4-7

Study Key Findings

Despite overall numbers of invasive pneumococcal disease decreasing, breakthrough infections (e.g., those caused by PCV13 strains), do occur.  This study found that 30% of the cases were caused by PCV13 strains, particularly pneumonia and mastoiditis.¹. In contrast, infections such as bacteremia, meningitis, peritonitis, and bone and joint infections were more commonly caused by strains not covered by the PCV13 vaccine.¹ It is estimated that up to 23% of the isolates with non-PCV13 strains may be covered by the newer vaccines.¹

Fortunately, non-CNS isolates were reported to have low non-susceptibility rates to both penicillin (4%) and ceftriaxone (3%).  Of those that were resistant, they continued to be primarily caused by serotype 19A.  Concerningly, meningitis isolates that were tested using CNS breakpoints demonstrated higher rates of non-susceptibility with about 40% non-susceptible to penicillin and 10% to ceftriaxone (majority were serotypes 19A and 35B).¹  This suggests there is continued need to use combination empiric therapy for meningitis in children.

Pharmacist Considerations

For pharmacists, these findings reinforce empiric therapy recommendations.  Amoxicillin (or amoxicillin/clavulanate for mastoiditis) remains appropriate for most invasive pneumococcal infections in children (e.g., pneumonia, mastoiditis).  Unfortunately, neither penicillin nor ceftriaxone should be relied upon alone for empiric pneumococcal meningitis treatment, instead vancomycin still should be combined with ceftriaxone.

As broader spectrum PCVs (i.e., PCV15, PCV20) are now commonly used, ongoing surveillance for pneumococcal serotypes and resistances will be important to guide future antibiotic treatment recommendations.

 

References

1. Kaplan SL, Barson WJ, Ling Lin P, et al. Invasive Pneumococcal Disease at Eight Children’s Hospitals in the United States, 2018-2023. Pediatr Infect Dis J. 2025
2. Centers for Disease Control and Prevention. Pneumococcal Disease Surveillance and Trends. Accessed November 11, 2025 https://www.cdc.gov/pneumococcal/php/surveillance/index.html
3. Centers for Disease Control and Prevention (CDC). Licensure of a 13-valent pneumococcal conjugate vaccine (PCV13) and recommendations for use among children – Advisory Committee on Immunization Practices (ACIP), 2010. MMWR Morb Mortal Wkly Rep. 2010;59(9):258–261
4. Kobayashi M, Farrar JL, Gierke R, et al. Use of 15-Valent Pneumococcal Conjugate Vaccine Among U.S. Children: Updated Recommendations of the Advisory Committee on Immunization Practices – United States, 2022. MMWR Morb Mortal Wkly Rep. 2022;71(37):1174–1181
5. American Academy of Family Physicians. Immunization Schedules. Accessed November 13, 2025https://www.aafp.org/family-physician/patient-care/prevention-wellness/immunizations-vaccines/immunization-schedules.html
6. American Academy of Pediatrics, Committee on Infectious Diseases. Red Book : Report of the Committee on Infectious Diseases 2024 – 2027. AAP Immunization Schedule. Accessed November 14, 2025https://publications.aap.org/redbook/resources/15585
7. ACIP Updates: Recommendations for Use of 20-Valent Pneumococcal Conjugate Vaccine in Children – United States, 2023MMWR Morb Mortal Wkly Rep. 2023;72(39):1072

The Essential Role of Pharmacists in Pediatric COVID-19 Vaccination

Evidence shows that pharmacists played a key role in COVID-19 vaccines for patients of all ages, including children, during the peak of the pandemic. Specifically, in the first three years of the pandemic (12/2020 – 9/2023) pharmacists provided 13 – 57% of all pediatric COVID-19 vaccines.¹ Although most children receive most of their vaccines at their doctor’s office, survey data suggests about 15% (especially teens and those in cities) obtain routine vaccines from pharmacies.² The pharmacist is the most accessible healthcare provider, with 89% of American’s living within 5 miles of a pharmacy.³ Thus, pharmacies remain an essential access point for vaccines for children.

Making Sense of COVID-19 Vaccine Recommendations for Kids

In recent months, the rules for when one can and should recommend COVID-19 vaccines to children has become confusing. The Advisory Committee on Immunization Practices has voted and Centers for Disease Control and Prevention (CDC) have changed COVID-19 vaccine for those 6 months and older to a shared clinical decision recommendation.⁴ It is important that it remains recommended at least at this level, as this will allow it to be paid for by the VFC program.

Meanwhile, the American Academy of Pediatrics (AAP) has made a stronger statement clearly recommending the COVID-19 vaccine for all infants and children 6 months through 23 months of age, as well as those 2 through 18 years old who: are unvaccinated, are at high risk of severe COVID-19 disease, live in congregate settings, have household members at high risk of severe COVID-19 disease, or whose parent/guardian wishes to provide them with additional protection.⁵

It is important to note, although confusing, these vaccine recommendations are not in conflict but rather differ in emphasis. The AAP guidance more clearly states which children are at highest risk and should be recommended to receive the vaccine while the CDC allows for individual decision-making. Notably, the CDC report shows that children < 2 years of age are at one of the highest risks of being hospitalized from COVID-19 disease, second only to those > 75 years old.⁶ As such, it is clear why this age is a routine recommendation, per the AAP. The AAP provides clear evidence for each of their recommendations in their COVID-19 specific recommendations.⁷

Which Pediatric Patients are Pharmacists Authorized to Vaccinate Against COVID-19 in 2025-26?

Which of our pediatric patients can we as pharmacists provide the COVID-19 vaccine to?  That partially depends on which state one is practicing.  The 12^th PREP Act extension allows pharmacists in every state to continue to provide COVID-19 and flu vaccines down to 3 years of age, in accordance with ACIP/CDC recommendations.⁸  Beyond this federal authorization, vaccine administration regulations revert to each state’s law.  We published an updated chart with links in a recent JPPT article to help clarify these requirements and provide you with quick access to state-specifics.⁹

References

1. El Kalach R, Jones-Jack NH, Grabenstein JD, et al. Pharmacists’ answer to the COVID-19 pandemic: Contribution of the Federal Retail Pharmacy Program to COVID-19 vaccination across sociodemographic characteristics-United States. J Am Pharm Assoc (2003). 2025;65(1):102305
2. Kang Y, Zhang F, Vogt TM. Where do children get vaccinated in the U.S.? Parental experiences, attitudes, and beliefs about place of vaccination with a focus on pharmacies and schools. 2025;62:126801
3. Berenbrok LA, Tang S, Gabriel N, et al. Access to community pharmacies: A nationwide geographic information systems cross-sectional analysis. J Am Pharm Assoc (2003). 2022;62(6):1816–1822.e2
4. Centers for Disease Control and Prevention. Child and Adolescent Immunization Schedule by Age (Addendum updated August 7, 2025). Accessed September 20, 2025https://www.cdc.gov/vaccines/hcp/imz-schedules/child-adolescent-age.html
5. American Academy of Pediatrics, Committee on Infectious Diseases. Red Book : Report of the Committee on Infectious Diseases 2024 – 2027. AAP Immunization Schedule. Accessed September 20, 2025https://publications.aap.org/redbook/resources/15585
6. Centers of Disease and Prevention. Updates to COVID-19 epidemiology. 2025. https://www.cdc.gov/acip/downloads/slides-2025-09-18-19/02-Srinivasan-covid-508.pdf
7. Committee on Infectious Diseases. Recommendations for COVID-19 Vaccines in Infants, Children, and Adolescents: Policy Statement. 2025
8. Health and Human Services Department. 12th Amendment to Declaration Under the Public Readiness and Emergency Preparedness Act for Medical Countermeasures Against COVID-19. 2024;89(238):99875–99883. https://www.federalregister.gov/documents/2024/12/11/2024-29108/12th-amendment-to-declaration-under-the-public-readiness-and-emergency-preparedness-act-for-medical#:~:text=The%20Public%20Readiness%20and%20Emergency%20Preparedness%20(PREP)%20Act%20authorizes%20the,relating%20to%2C%20or%20resulting%20from
9. Girotto JE, Warminski S, Oz T, Fly JH. Continuing as Partners in Immunization: Updates to Practice and Legislation for Pediatric Pharmacy Immunizations. J Pediatr Pharmacol Ther. 2025;30(5):691–695