Evidence behind the WHO guidelines: Hospital care for children

A combination of ampicillin and gentamicin as first line therapy for suspected non-meningitic septicaemia in children is apprropriate first-line therapy. Ampicilin should be given in high dose (200-300 mg/kg/day) to overcome penicillin-resistance among pneumococci. Once daily gentamicin has been proven to be safe, effective and associated with less toxicity than more frequent doses. Where meningitis is suspected, the options are chloramphenicol of a third-generation cephalosporin. A third-generation cephalosporin (e.g. ceftriaxone) will be preferable to chloramphenicol where resistance to chloramphenicol and penicillin among H. influenzae and S. pneumoniae is common. Anti-staphylococcal antibiotics (such as betalactamase stable penicillins flucloxacillin or cloxacillin) should be given as first-line treatment if there are suggestive skin lesions, abscesses, bone or joint infection, or if other signs of staphylococcal infection (such as pneumatocoeles or empyema) are present. If either flucloxacillin or cloxacillin are not available, chloramphenicol will have some anti-staphylococcal activity. Further studies are needed to follow antimicrobial susceptibility in developing counries so that empirical treatment recommendations maintain a strong evidence base. Restricting the use of third-generation cephalosporins and beta-lactamase stable penicillins to where there are specific indications will reduce the development of antibiotic resistance.