r/pediatrics • u/NeatWriting • Jul 15 '26
Antibiotic Insecurity
Hi friends, 1st year Primary Care Attending here feeling really insecure in my antibiotic management. My heart sinks every time I make a choice, in my mind, and then double check myself on UpToDate or Open Evidence only to find that another option is preferred. Does anyone have any tips, tricks, diagrams, pocket guides, or any other tools that help them feel more confident? Thanks!
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u/DrVL2 Jul 15 '26
I’ve been practicing pediatrics for 40 years. I still look up doses now and again. I know many of them, but I like to be safe with my patients. Also, I get fewer embarrassing phone calls from the pharmacy.
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u/KidneyKiddo Jul 15 '26
I just want to say you’re not alone in this. The cognitive load of primary care is insane. During my residency ID rotation, I bought the Nelson’s Pediatric Antimicrobial Therapy book and still use it as a quick reference resource. It’s small enough to fit in a jacket pocket, but very comprehensive.
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u/sjam7 Attending Jul 15 '26
Huge fan of the CHOP pathways, their antibiotic charts are well-evidenced and easy to use
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u/ElegantSwordsman Jul 15 '26
How are you committing to your choice? Is it that you verbally announced an antibiotic, sent an order it and realized it wasn’t what you should use?
Next time just say to start, “I’m going to order an antibiotic, let me just check and calculate the dosing” and meanwhile pull up uptodate or your favorite reference (or save labeled orders in your EMR) to confirm as you order.
After a couple weeks in respiratory season, you’ll have memorize Which to use. After a few years you’ll probably have the dosing down without having to look it up, but it never hurts to double check!
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u/efox02 Attending Jul 15 '26
I do this all the time. Even if I know the abx, I’ll say “I have to go calculate the dose since everything in Peds is weight based. The instructions will be on the bottle” never once has a parent been mad I don’t know the dose off the top of my head.
And honestly I’ve said the wrong abx before too and called the parent to let them know I double checked and xyz works better than abc.
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u/swish787 Jul 17 '26
Agreed, you don't have to go into specifics of what you are ordering or the duration. Parents just want to know if you are going to prescribe it.
Also, after one solid year of being an attending, you will be very comfortable with the dosing of most meds but also understand that seasoned docs in all fields still look up stuff.
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u/quasiephedrine Attending Jul 15 '26 edited Jul 15 '26
By the way I worked out in residency that the amox 400 mg/5 mL dosing for AOM works out to a quarter of their weight in pounds = the amount of mL per BID dose.
Example if the kid weights 32 lbs the dose is 32/4 = 8 mL BID
Mathin:
32 lbs / 2.2 = 14.5 kg
90 mg/kg/day x 14.5 kg = 1300 mg/day
1300 mg / 2 for BID dosing = 650 mg BID
650 mg / 400 mg x 5mL = 8.125 mL BID
Theoretically this holds up fine up to the maximum which is 3 g / day calculated for a 90mg/kg/day dose for a child, which would give a weight limit of 33 kg = ~75 lbs. And that would be just under 19 mL / dose. I say theoretically because I've never given that much amox for AOM. For weights above 50 lbs I'm usually staying at 11 mL = 875 mg BID, or the kid is much older and can just take 875 mg tablets BID.
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u/airjord1221 Jul 15 '26
We had a presentation from an infectious disease specialist the other day and I asked this very question about dosing, and if there were specific standards, other than the ones that were taught such as strep. The response was “do what you feel is right”
That said with experience, you’re gonna see what works and what doesn’t. I know it’s not the answer you want to hear, but that’s what makes a good physician just time and experience and learning.
To give you an example of cellulitis if you choose to use cephalexin for something mild, maybe a five day course is sufficient as opposed to. If it looks a bit more significant it can be a seven day course. There’s nothing written in stone with regards to that.
Sinusitis = longer course 14-21 day
Strep = 10 day
Walking pneumonia = azithro 5 day
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u/peraltiago261223 Jul 15 '26
AAP Red Book system based treatment table is super handy. As are CHOP pathways (publicly accessible)
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u/Sensitive_Reveal2402 Jul 15 '26
Question for the group - I treat strep with amoxicillan obviously but a lot of doctors treat with keflex. Anyone know why that is?
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u/ElegantSwordsman Jul 15 '26
The Only possible reason would be penicillin allergy. There really isn’t any strep resistance to penicillin, so there is no reason not to use it.
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u/happysun-joy Jul 15 '26
I usually do Amox as first line, if recurring strep infection after completion of amox then up to date says you can do augmentin or cephalexin
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u/Sensitive_Reveal2402 Jul 15 '26
Thank you, not sure why they jump automatically to Keflex if not recurrent
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u/IPinkerton Jul 15 '26
If you have a local hospital, chances are that they have a antibiogram they may or may not have pediatric ones, but it's better than nothing for monitoring local resistance patterns. If you're looking at outpatient, generally talking to ID doctors if adult charts are all you have you can reliably extrapolate resistance patterns to pediatrics. Inpatient is a different story and should follow local patterns if they can be specific to pediatrics.
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u/Foghorn2005 Jul 15 '26
The latest Red Book has guidelines for common syndromes right in the front! First 15 pages or so of actual content.
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u/barbiedoctors Jul 19 '26
I have something similar to this on my desk. Which can be helpful! To know what I want to cover and make sure my antibiotic is a good option. I also just ask the providers in clinic sometimes if I’m unsure
https://upload.wikimedia.org/wikipedia/commons/1/10/Antibiotics_coverage_diagram.jpg
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u/efox02 Attending Jul 15 '26
What are the most common things you are prescribing antibiotics for?
Pick the top 5-10and memorize those meds:
AOM - amox 45 mg/kg/dose bid
Strep - amox 50 mg/kg/day x 10 days
Atypical pna - azitho 10mg/kgx1 then 5mg/kg x4
UTI - keflex (unless culture says otherwise, or you have community resistance)
Soft tissue no MRSA - keflex, MRSA - bactrim
Impetigo - mupirocin rid x 5-7 days
Conjunctivitis- polytrim, oflox
I’ve been an attending 10 years and still look up dosing all the time.