MedBalans

First-line therapy

Piperacillin/tazobactam • i.v. • 100–100 mg/kg/dose • 4×/day

Dose is calculated using the piperacillin component.

Max 4500 mg/dose (piperacillin) · Max 18000 mg/day · Duration: 14–21 days · Individualize to source control and response — often 2–4+ weeks total for deep infection, retained foreign material, esophageal perforation, or slow clinical/radiologic resolution

• Deep infection with polymicrobial contamination suspected (e.g., esophageal perforation)
• Clinical instability or rapidly progressive infection

Enter weight on Kids to calculate doses

Ceftriaxone • i.v. • 50–75 mg/kg/day • 1×/day

Max 2000 mg/day · Duration: 14–21 days · Use when piperacillin/tazobactam is not suitable; narrow to culture-directed therapy as soon as susceptibilities are available

Enter weight on Kids to calculate doses

Clinical notes

• Common causes: postoperative (cardiac/thoracic surgery, sternal wound infection), descending neck infection (deep neck space infection), and esophageal perforation/leak (including instrumentation).

• Urgent surgical/thoracic surgery consult is required for suspected mediastinitis; do not delay source control for imaging when the child is unstable.
• Drainage/debridement is indicated for mediastinal collections, ongoing air/fluid leak, necrotizing infection, sternal instability, or failure to improve within 24–48 h on appropriate therapy.
• Obtain blood cultures and (when feasible before antibiotics) mediastinal/pleural/operative specimens for Gram stain and aerobic/anaerobic culture; tailor antibiotics to results and local resistance patterns.
• IV→PO switch: consider only after adequate source control, hemodynamic stability, afebrile trend, improving inflammatory markers, tolerating oral intake, and a clear oral target regimen based on cultures; duration depends on response and adequacy of drainage.

• AAP Red Book — Principles of management for deep infections (MRSA coverage and culture-directed therapy) (2024)
• IDSA — Practice guidelines for skin and soft tissue infections (severe infection/MRSA principles applicable) (2014)
• CPS — Deep neck infection / retropharyngeal abscess principles (descending mediastinitis risk and airway/source control) (2026)

+ 2 more

• ESPID — Guidance on severe pediatric infections and antimicrobial stewardship (culture-directed narrowing principles) (2024)
• Pediatric surgery / thoracic surgery guidance — postoperative mediastinitis and descending necrotizing mediastinitis (source control and prolonged therapy principles) (2023)

Mediastinitis

First-line therapy

Clinical notes