Cefotaxime, historically the preferred 3rd generation cephalosporin for neonates, is no longer manufactured.  

• Ceftazidime is an alternative, however, it is broader in spectrum with antipseudomonal activity and increased use may impact gut microbiota and contribute to antibiotic resistance.  
• Ceftriaxone may be considered in neonates without contraindications: 
  • Avoid use in neonates receiving IV calcium-containing solutions due to reports of death and serious adverse events with calcium-ceftriaxone deposits in neonatal vasculature with concomitant use. This is a potential risk regardless of route of administration even if ceftriaxone is given intramuscularly.  
  • Avoid use in neonates with hyperbilirubinemia due to potential for displacement of bilirubin from albumin with theoretical potential for kernicterus or bilirubin encephalopathy.   

*Note these contraindications apply specifically to neonates but not to older infants (>44 weeks corrected gestational age) or children 

See further CAP management guidelines from the UCSF Northern California Pediatric Hospital Medicine Consortium, though reference below recommendations for updated antibiotic selection. 

At BCH OAK follow site-specific CAP algorithm (link requires password log in to Box); recommendations provided below are compatible with BCH OAK CAP algorithm, but the algorithm provides additional details in pathway form.   

Best Practices for Antibiotic Use: 

• Avoid using antibiotics when bacterial infection is unlikely. Learn to recognize colonization and contamination in cultures and other etiologies of false positive diagnostic tests. Choose carefully when to send a diagnostic test for infection.  
• Obtain appropriate cultures and other diagnostic testing when indicated.  
• Select empiric antimicrobial therapy based on likely pathogens, using the BCH Empiric Antimicrobial Therapy Guidelines and hospital-specific antibiogram for guidance.  
  • BCH OAK Antibiogram 
  • BCH SF Antibiogram
• Determine appropriate dose based on site and severity of infection, using BCH Empiric Antimicrobial Therapy Guidelines and Dosing Guidelines, or Lexi-Comp.  
• Within 48-72 hours, re-evaluate therapy to target the likely diagnosis, and when available, based on culture and susceptibility data.  
  • If a specific source or pathogen is not identified it is recommended to de-escalate therapy in most circumstances 
  • Discontinue antimicrobials when an indication no longer exists (e.g. vancomycin if cultures do not show MRSA). 
  • Use the narrowest regimen likely to be effective.  
• Switch from IV to enteral therapy as soon as it is clinically appropriate.  
• Treat with the shortest duration of therapy that is likely to be effective for the presumed or proven infection.  
• Contact the Antimicrobial Stewardship team at your patient’s campus for advice at any point you feel you may need more help.  

Spectrum of Activity 

Below are resources that may be helpful in gauging the spectrum of activity (how broad or narrow an antibiotic is) and figuring out what categories of bacteria might be treated by different antibiotic choices.   

This is a simplified table that shows the general pattern of activity of different antibiotics against major categories of bacteria. For more details, see the antibiograms linked above. 

The following table may be helpful when choosing between different antibiotic options, and is based on the 2019 World Health Organization AWaRe (Access, Watch, Reserve) classification of antibiotics for evaluation and monitoring of use. See second row of table below for more information about what these terms mean.  

*This category has been added to signal those antibiotics that are still considered relatively broad in spectrum within the “Access” group. 

**This category has been added to signal those antibiotics with the broadest spectrum of activity within the “Watch” group.  

This supplemental section provides guidance on interpreting the "Alternative Therapy" recommendations in the Benioff Children's Hospitals Empiric Antimicrobial Therapy Guidelines for patients with antibiotic allergies, and caring for patients with documented antibiotic allergies: 

• Many patients report a history of an antibiotic allergic reaction, most commonly to beta-lactam antibiotics (e.g. penicillins or cephalosporins). 
• In some cases alternative recommendations are provided to help guide therapy when there is concern for a history of allergy that may limit first choice therapy. These alternative recommendations may stratify by characteristics of a patient’s reported previous reaction (“Higher risk” vs “lower risk for allergic reaction”), as well as the class of the labeled antibiotic allergy (penicillin and/or cephalosporin class antibiotics). 

While the Empiric Antimicrobial Therapy Guidelines may provide alternative recommendations for antibiotic therapy, it is recommended to evaluate the antibiotic allergy, and take steps to remove the label if appropriate.  

Resources to evaluate beta-lactam antibiotic allergies at UCSF 

The above guidelines are based on the UCSF Inpatient Beta-Lactam Allergy Guideline, which is a comprehensive resource with further guidance for: 

• Assessing allergy history for level of risk for subsequent reaction 
• Choosing medications that can be given with or without a test dose procedure, based on prior allergy history.   
• Guidance for test dose procedure; this is a safe procedure that can be performed on a hospital ward. At BCH, the IP PED Beta Lactam Allergy Test Dose Evaluation orderset should be used 

Referrals and consultations 

• ​Pediatric ID or Antimicrobial Stewardship teams are available for guidance on addressing a listed allergy vs. choosing alternative therapy 
• For any patient with a listed antibiotic allergy, consider an outpatient referral to Pediatric Allergy Clinic for delabeling assessment 

Why is assessment of antibiotic allergies important? 

Most reactions documented as antibiotic allergies are not true allergies: 

• Carrying an antibiotic allergy label is common: ~ 10 in 100 people have a labeled beta-lactam allergy (BLA) 
• The true prevalence of IgE-mediated antibiotic allergy is much lower (estimated ~ 1 in 100 for BLA); most people with a documented BLA could safely receive beta-lactam antibiotics.  
• Cross-reactivity rates between different beta-lactam antibiotics are low, and patients with true penicillin allergy can still safely receive many cephalosporins and carbapenems (and vice versa) 

Carrying an antibiotic allergy label can be harmful:  

• For many pediatric infectious conditions, a beta-lactam antibiotic is the first-line therapy. Patients with labeled antibiotic allergies often receive antibiotics that are less effective than first line therapy, and/or have higher toxicity risk and/or cost. 
• An allergy label placed during childhood may affect care across the lifespan; pediatric clinicians have a special responsibility to apply allergy labels judiciously and remove them when appropriate.  

What can you do to mitigate harm from antibiotic allergy labels?  

Gather careful history on any labeled allergy 

• Carefully assess the reported reaction to determine consistency with an allergic response. 
• Ask about and review medication administration history in electronic medical record to see if the patient has tolerated the antibiotic(s) in question in the past.  

Avoid labeling reactions as allergy if not consistent with a true allergic reaction:  

• Avoid documenting an allergy when signs and/or symptoms are consistent with an anticipated medication side effect such as diarrhea only, nausea only, or a local injection site reaction 
• Avoid documenting an antibiotic allergy in a patient based on a family history of antibiotic allergy in a relative.  
• Avoid diagnosing Amoxicillin allergy in patients who develop a delayed maculopapular rash as the only manifestation.
  • See "Rashes from amoxicillin: is it a true allergy?" and "Amoxicillin allergy & amoxicillin rash are often mislabeled" for more information on distinguishing these reactions. 
  • This is a common reaction ( ~5-10% of treated patients) that is not IgE-mediated and patients may safely continue or repeat therapy with Amoxicillin after experiencing this reaction. 

Educate patients and families 

• Families are more likely to have received education about the risks of a potential allergy than the risks of an inaccurate allergy label.  
• Patient-centered information resources include:   
  • Penicillin Allergy: Facts for Patients. College of Allergy, Asthma & Immunology  
  • Am I Allergic to Penicillin? JAMA Patient Page  
  • Penicillin Allergy - What do you need to know? American Academy of Allergy, Asthma & Immunology