:�

I

� I

CONTENTS

ARTICLES

123 Antifungal DrugsJ. Thomas Cross, ir, Steven L. Hickerson,

Terry Ya,nauchi

130 Autism and the Pervasive DevelopmentalDisorders: Part 1Stephen Bauer

137 Acute Renal Failure: TherapyAzra Sehic and Russell W. Chesnev

142 Diaper DermatitisSrisupalak Singalavanija and Ilona J. Frieden

148 Infective EndocarditisDelores Danilowic�

155 Index of SuspicionElliott M. Friedman, Ten Turner, Danuta Deeb

158 Consultation with the Specialist:Adolescent Social DevelopmentRobert L. Johnson

COVER

Working in the medium of batik, Paul Nzalamba creates images that are

drawn from his native country, Uganda, and that reflect the strength,struggle, and beauty of all people, especially children and adolescents. We

chose to use his “At Play” (1988) to show a modern, indigenous artist’swork that illustrates the color and joy of such artists. Mr. Nzalamba’sworks are on display at his studio in Los Angeles, California. Reproduced

with permisison.

ANSWER KEY

1. D; 2. C; 3. B; 4. A; 5. D; 6. B; 7. C; 8. D; 9. A; 10. B; 11. D; 12. C;13. A; 14. A; 15. E; 16. B; 17. B; 18. E; 19. B; 20. C; 21. A; 22. B; 23. A;

24. B; 25. A; 26. B; 27. C; 28. E

Printed in USA

Pediatrics in ReviewVol 16 No 4

April 1995

EDITORRobert J. Haggerty

University of Rochester

School of Medicine and Dentistry

Rochester, NY

Editorial Office:Department of Pediatrics

University of Rochester

School of Medicine and Dentistry601 Elmwood Aye, Box 777Rochester, NY 14642

ASSOCIATE EDITORLawrence F. Nazarian

Panorama Pediatric Group

Rochester, NY

CONSULTING EDITOR

Evan Chamey, Worcester, MA

ABSTRACTS EDITOR

Steven P. Shelov, Bronx, NY

MANAGING EDITORJo Largent, Elk Grove Village, IL

EDITORIAL CONSULTANT

Victor C. Vaughan, III, Stanford, CA

EDITORIAL BOARDMoris A. Angulo, Mineola, NYRussell W. Chesney, Memphis, TN

Peggy Copple, Tucson, AZ

Richard B. Goldbloom, Halifax, NS

John L. Green, Rochester, NYRobert L. Johnson, Newark, NJKathi Kemper, Seattle, WA

Alan M. Lake, Glen Aim, MDFrederick H. Lovejoy, Jr, Boston, MA

John T. McBride, Rochester, NYVincent J. Menna, Doylestown, PALawrence C. Pakula, Timonium, MD

John M. Pascoe, Madison, WIRonald L. Poland, Hershey, PA

James E. Rasmussen, Ann Arbor, MIKenneth B. Roberts, Worcester, MA

James S. Seidel, Torrance, CA

Richard H. Sills, Newark, NJ

Laurie J. Smith, Washington, DC

William B. Strong, Augusta, GAJon Tingelstad, Greenville, NC

Vernon T. Tolo, Los Angeles, CARobert J. Touloukian, New Haven, CT

Terry Yamauchi, Little Rock, ARMoritz M. Ziegler, Cincinnati, OH

EDITORIAL ASSISTANT

Sydney Sutherland

PUBLISHER

American Academy of Pediatrics

Errol R. Alden, MD, Deputy

Executive Director0. J. Sahler, MD, Director

Department of Education

Jean Dow, DirectorDivision of Medical Journals

Deborah Kuhlman, Copy Editor

PEDIATRICS IN REVIEW (ISSN 0191 -9601) is owned

and controlled by the American Academy of Pedi-atrics. It is published monthly by the AmericanAcademy of Pediatrics, 141 Northwest Point Blvd,

P0 Box 927, Elk Grove, IL 60009-0927.Statements and opinions expressed in Pediatncs

in Review are those of the authors and not neces-

sarily those of the American Academy of Pediatricsor its Committees. Recommendations included inthis publication do not indicate an exclusive course

of treatment or serve as a standard of medical care.Subscription price for 1995: AAP Fellow $105; AAP

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cular adverse effects, including death,

in patients receiving the drugs con-

comitantly. The use of astemizole

and loratadine also are contraindi-

cated because of similar adverse ef-

fects as with ketoconazole. Hepatic

enzyme tests should be monitored in

patients who have preexisting hepatic

function abnormalities.

Pediatrics in Review Vol. 16 No. 4 April 1995 /29

INFECTIOUS DISEASEAntifungal Drugs

Itraconazole is metabolized almost

exclusively in the liver, with fecalexcretion varying between 3% and18% and renal excretion at less than0.03% of the parent drug. No abnor-malities were noted in serum levelsamong patients who had renal im-pairment. Limited data suggest thatthose patients who have hepatic dys-function should have their liver func-

tion monitored while receiving itra-conazole therapy.

CLINICAL USES

The data on itraconazole’s therapeu-tic efficacy are limited; no random-ized, blinded trials comparing it withamphotericin B have been published.Limited data suggest that it is moreeffective in treating tinea corporis andtinea cruris than is griseofulvin. Ex-perience with the drug shows excel-bent activity against histoplasmosis,blastomycosis, and sporotrichosis,and it now may be considered thedrug of choice for these infections.

Infection with phaeohyphomycosesresponds to this agent, according to

anecdotal reports.Its use in meningitis is limited, and

it cannot be recommended for CNSinfections, although patients whohave cryptococcal meningitis havebeen reported to have been treatedsuccessfully. Its use in patients whohave invasive aspergilbosis is promis-ing but will depend on the results ofcontrolled studies that currently areunderway. At present, indications arefor blastomycosis (pulmonary andextrapulmonary) and for histoplasmo-sis (including chronic cavitary pul-monary disease and disseminated,nonmeningeal histoplasmosis). Itra-conazole appears to be superior to

fluconazole or ketoconazole as pri-mary therapy or suppressive therapyof histoplasmosis in patients whohave AIDS.

TOXICITY

The most common adverse reactions

associated with itraconazole use in-clude nausea, vomiting, and rash,which are more common in immuno-compromised patients. Coadministra-tion of terfenadine and itraconazobe is

contraindicated because there havebeen rare cases of serious cardiovas-

DOSAGE AND ADMINISTRATION

The recommended dose of itracon-

azobe for adults for most infections is

200 mg once daily. A dose in new-

borns of 10 mg/kg was used success-

fully in one case report, but no other

data exist on the safety and efficacy

of this dose in other children. Most

likely, a dose of 5 to 10 mg/kg per

day will be effective for children;

however, caution must be exercised

until other controlled trials of this

agent are published.

SUGGESTED READINGBaley JE, Meyers C, Kliegman RM, et al.

Pharmacokinetics, outcome of treatment,

and toxic effects of amphotericin B and

5-fluorocytosine in neonates. J Pediatr.

1990;l 16:791-797

Bodey OP. Azole antifungal agents. Clin Infect

Dis. 1992;14(suppl 1):S16l-S169

Gallis HA, Drew RH. Pickard WW. Ampho-

tericin B: 30 years of clinical experience.

Rev Infect Dis. 1990;12:308-329

Grant SM, Clissold SP. Itraconazole: a review

of its pharmacodynamic and pharma-

cokinetic properties and therapeutic use in

superficial and systemic mycosis. Drugs.

1989;37:310-344

Heel RC, Brogden RN, Carmine A, et al.

Ketoconazole: a review of its therapeutic

efficacy in superficial and systemic fungal

infections. Drugs. 1982:23:1-36

Hoeprich PD. Clinical use of amphotericin B

and derivatives: lore, mystique, and fact.

C/in Infect Dis. l992;l4(suppl 1):Sl 14-

S119

Kowaisky SF, Dixon DM. Fluconazole: a new

antifungal agent. Clin Pharmacy. 1991:10:

179-194

Lee JW, Seibel NL, Amantea M, et al. Safety

and pharmacokinetics of Iluconazole in

children with neoplastic diseases. J Pediatr.

1992:120:987-993

Meyer RD. Current role of therapy with ampho-

tericin B. Clin Infect Dis. 1992:14(suppl

l):S 154-S 160

Symoens J, Moens M, Dom J. et al. An

evaluation of two years of clinical

experience with ketoconazole. Rev Infect

Dis. 1980:2:674-691

PIR QUIZMatch each antifungal drug listed be-

low with the statement that best charac-

tenses its oral use.

I. Amphotericin B

2. Fluconazole

3. Itraconazole

4. Ketoconazole

A. First orally bioavailable, broad-

spectrum antifungal drug.

B. Oral bioavailability is aug-

mented dramatically by inges-

tion of food.

C. Oral bioavailability remains

high when gastric pH is ele-

vated.

D. Oral bioavailability is unaccept-

ably low under all conditions.

5. A 10-year-old girl has a chronic

ulcer on her right index finger; cul-

ture reveals Sporothrix schenckii.

The most appropriate choice of

therapy is:

A. Amphotericin B.

B. Fluconazole.

C. Flucytosine.

D. Itraconazole.

E. Ketoconazole.

6. A 17-year-old girl who requires

daily prednisone to control renal

manifestations of systemic lupus

erythematosus develops cryptococ-

cal meningitis. The most appropri-

ate choice of therapy is a combina-

tion of:

A. Amphotericin B and flucon-

azole.

B. Amphotericin B and flucytosine.

C. Amphotericin B and itracon-

azole.D. Amphotericin B and rifampin.

E. Amphotericin B and tetracy-

cline.

Match each antifungal drug listed be-

low with itsmost characteristic adverse

effect.

7. Amphotericin B

8. Fluconazole

9. Flucytosine

10. Ketoconazole

A. Bone marrow failure.

B. Gynecomastia.

C. Nephrotoxicity.

D. Stevens-Johnson syndrome.

11. A 10-year-old boy recovering from

cadaveric renal transplantation de-

velops candidal cystitis. You con-

sider oral fiuconazole as a thera-

peutic alternative to amphotencin B

bladder washes. In this setting, you

should be most concerned about the

interaction of fluconazole with:

A. Astemizole.

B. Calcium carbonate.

C. Cimetidine.

D. Cyclosporine.

E. Ranitidine.

Pediatrics in Review Vol. /6 No. 4 April 1995 141

RENAL DISEASERenal Failure

Prevention

Prevention of ARF, obviously, is the

best form of therapy. Certain clinicalsituations may predispose to the de-velopment of ARF and should be

recognized. Some preventive mea-sures include:

I . Monitor the patient at risk.2. Provide adequate hydration and

maintenance of extracellular fluid

volume (ECV) prior to the admin-istration of radiocontrast material,amphotencin B, or aminogly-cosides.

3. Administer nephrotoxic drugs inappropriate doses and monitor

drug levels carefully. If possible,use alternative medication andlimit the length of patient expo-sure.

4. Alkalize urine (pH >6.5) and ade-quately hydrate patients who havehyperuricemia or pigmenturia.

5. Use xanthine oxidase inhibitors to

prevent hyperuricemia, such as intumor lysis syndrome.

6. Treat prerenal conditions promptlyvia intravenous fluid to expand

ECV and via osmotic and loopdiuretics to increase blood flowand decrease cast formation ifcardiovascular status allows.

7. Administer low-dose dopamineinfusion (3 to 5 p.g/kg per minute)to patients who are in cardiac fail-ure and have other conditions thatcompromise renal perfusion.

8. Ameliorate ARF with nutrients

and hormones; vasodilatators andcytoprotective agents can help.Experimental studies have mdi-

cated a role for the followingagents in animal studies and lim-ited clinical trials. However, thebeneficial effects of thyroxine,

atrial natriuretic factor, insulingrowth factor, prostaglandin ana-logs, adenosine triphosphate-mag-nesium chloride, calcium channelblockers, and dopamine need to beestablished more firmly.

SUGGESTED READINGBadr KF, Ichikawa I. Prerenal failure: a

deleterious shift from renal compensation to

decompensation. N Engl J Med. 1988;3l9:

623-629

Beck F. Thurau K, Gstraunthaler G. Patho-physiology and pathobiochemistry of acute

renal failure. In: Seldin DW, Giebisch G,

eds. The Kidney: Physiology and Patho-

physiology. New York. NY: Raven Press:

1992:3 157-3 179

Druml W. Nutritional support in acute renal

failure. C/in Nutr. 1993:12:196-207

Feld LG, Cachero 5, Springate JE. Fluid needs

in acute renal failure. Pediatr C/in North

Am. l990;37:337-350

Feld LG, Springate JE. Acute renal failure. In:

Barakat A, ed. Renal Disease in Ghildren:

Clinical Evaluation and Diagnosis. New

York. NY: Springer-Verlag, mc; 1990:269-

284

PIR QUIZ

I 2. The most frequent cause of pre-

renal failure in the pediatric age

group is:

A. Cardiomyopathy.

B. Diabetic acidosis.

C. Gastroenteritis.

D. Hemolytic anemia.

E. Hypersensitivity vasculitis.

13. A 5-year-old boy is admitted with

a 2-day history of facial puffiness,

severe headache with nonbilious

emesis, and scant painless, bloody

urine. Blood pressure is 174/98

mm Hg. Two weeks previously he

had a skin infection that allegedly

cleared with antibiotic therapy. Re-

suIts of laboratory tests include:

hemoglobin 10.5 g/dL, BUN

84 mg/dL. and serum creatinine

4.4 mg/dL. The urinary sediment

contains red blood cell and white

blood cell casts, and the stain for

eosinophils is negative. Two sym-

metrically enlarged kidneys are

identified on renal ultrasonography.The most likely diagnosis is:

A. Acute postinfectious glomerulo-

nephritis.

B. Antibiotic-associated interstitial

nephritis.

C. Bilateral partial ureteral obstruc-

tion.

D. Hematogenous bacterial pyelo-

nephritis.

E. Hemolytic-uremic syndrome.

14. Acute renal failure of intrinsic ori-

gin is suspected in a 3-year-old

girl. Of the following, the labora-

tory result most supportive of that

diagnosis is:

A. Fractional excretion of sodium

(FENa) > 3%.

B. Urine osmolality of 450 mOsm.

C. Urine/plasma creatinine ratio of

40:1.

D. Urine/plasma urea ratio of 12:1.

Finn WF. Diagnosis and management of acute

tubular necrosis. Med C/in North, Am. I 990;

74:873-891

Gaudio KM. Siegel NJ. New approaches to the

treatment of acute renal failure Pediatr

Nephirol. 1987: 1 :339 -347

Jones DP, Chesney RW. Glomerulotubular

dysfunction and acute renal failure. In:

Fuhrman BP, Zimmerman JJ, eds. Pediatric

Critical (‘are. St. Louis, MO: Mosby

Yearbook. I 992:697-709-

15. Acute renal failure has been diag-

nosed in an 8-year-old boy who

previously was healthy. On exami-

nation. he has a clear sensorium

and mild generalized edema. His

blood pressure is 138/86 mm Hg,

hemoglobin is 9.8 g/dL, BUN is

84 mg/dL, serum creatinine is

4.6 mg/dL, serum sodium is

I 30 mEq/L, serum potassium is

5.6 mEq/L. and serum HCO3 is

14 mEq/L. Urine output is 15 to

20 mL/day. In the management of

his fluid, electrolyes, and nutrition

therapy, the most correct statement

is:

A. Active hemolysis reduces main-

tenance sodium requirements.

B. Daily caloric intake should be

distributed equally among car-

bohydrate, fat, and protein.

C. Estimated insensible loss should

be replaced with 0.9% sodium

chloride.

D. Serum sodium and bicarbonate

require prompt correction to

normal ranges.

E. Weight loss should approximate

1% of body weight per day.

16. A 5-year-old girl is admiued with

acute renal failure associated with

the hemolytic-uremic syndrome.

She is alert, and hydration appears

normal. Results of laboratory tests

include: hemoglobin 8.5 g/dL.

BUN 64 mg/dL, serum creatinine

3.8 mg/dL, serum sodium

136 mEq/L, serum potassium

7.0 mEq/L, and serum HCO1

14 mEqfL. The admission electro-

cardiogram shows a prolonged P-R

interval and peaked T waves. The

most appropriate immediate step in

her treatment program is:

A. Correct anemia by transfusion

with fresh packed red blood

cells.

B. Give calcium gluconate 10%

0.5 to 1.0 mL/kg per dose intra-

venously.

C. Give glucose I g/kg plus insulin

0.1 U/kg intravenously.

D. Give sodium polystyrene sul-

fonate I g/kg orally.

E. Transfer to referral center for

dialysis.

PIR QUIZ

17. After staying with a baby sitter

over a weekend, a 6-month-old girl

develops a diaper rash. The girl

appears well. You note an erythem-

atous, slightly scaly eruption over

her buttocks, lower abdominal wall,

labia majora, and proximal thighs,

with sparing of the inguinal folds.

The remainder of her examination

is unremarkable. The most appro-

priate diagnosis is:

A. Candidal dermatitis.

B. Irritant dermatitis.C. Miliaria.

D. Psoriasis.

E. Seborrheic dermatitis.

Match each of the following sets of

clinical findings with the appropriate

infectious agent.

19. Flaccid bullae and pustules over

proximal thighs and lower abdomi-

nal wall.

20. Moist erosions in diaper area; des-

quamation of palms and soles.

21. Red, scaly plaques in inguinal

folds; satellite papules and pustules.

A. Candida albicans

B. Staphylococcus aureus

C. Treponema pallidum

18. A 5-month-old girl has a diaper

rash that has persisted for 1 month

despite two courses of nystatin.

The girl is otherwise healthy. An

erythematous, scaly rash is present

in the inguinal folds, behind the

ears, and over the scalp. The re-

mainder of her examination is un-

remarkable. The most appropriate

diagnosis is:A. Atopic dermatitis.B. Letterer-Siwe disease.

C. Psoriasis.

D. Psoriasiform id reaction.

E. Seborrheic dermatitis.

22. A previously well 6-month-old girlhas had an erythematous, slightly

scaly eruption over her buttocks,

lower abdominal wall, labia ma-

jora, and proximal thighs for the

past 2 days. The inguinal creases

are spared. Appropriate manage-

ment would include switching to

ultraabsorbent diapers, more fre-

quent diaper changes, and:

A. Coal tar ointment.

B. Desitin#{174} cream.

C. Mycolog Il#{174}cream.

D. Nystatin cream.

E. Triamcinolone cream (0.025%).

23. A parent can best prevent irritant

diaper dermatitis in a healthy

6-month-old infant by:

A. Changing diapers frequently.

B. Increasing dietary ascorbic acidcontent.

C. Switching from breast to

formula feeding.

D. Using cloth diapers in place of

disposable ones.

E. Using commercial diaper wipes

regularly.

Pediatrics in Review to Hold 1996Cover Art Co ntest: Works by C h lid ren!

In 1996, we plan to display a pieceof art by children on the covers ofour 1996 issues. Four pictures will

be chosen, and the cover artwork

will be changed quarterly.

Rules of the Contest

Pediatricians: Please have your

patients send art they would like

considered to:

1 . The contest will run from Janu-any through July 1995. (Winners

will be chosen in August 1995

for display in 1996. PRIZESwill be awarded to each winner!)

2. The theme of each submission:Draw a picture of you (ie, the

child/adolescent artist) doingyour favorite thing.

3. Qualification: The artist must beeither between the ages of a) 5

and 10 years or b) 1 1 and 15

years. (There will be two cate-

gories, by age, for submissionand judging.)

4. Requirements: The picture mustbe in color and be reproducible

to a size of 3 inches by 4

inches. FREE HINT TOARTISTS: Think Big! Smalldetails don’t show up as well.

Sydney Sutherland,

Editorial Assistant

Pediatrics in Review

do The Department of

Pediatrics, Box 777

University of Rochester Medical

Center601 Elmwood AvenueRochester, NY 14642

(716) 275-0170

Pediatrics in Review Vol. 16 No. 4 April 1995 /47

. . DERMATOLOGY� . �- Diaper Dermatitis

ammonia dermatitis of the gluteal regon of

infants. Am J Dis Child. l92l;22:481-492

Dixon PN, Warm RP, English MP. Role of

Candida albicans infection in napkin rashes.

Br Med J. 1969;2:23-27

Goldberg NS. Esterly NB, Rothman KF, et al.

Perianal pseudoverrucous papules and

nodules in children. Arch Dermatol. 1992;

I 28:240-242

Hara M, Watanabe M, Tagami H. Jacquet

erosive diaper dermatitis in a young girl

with urinary incontinence. Pediatr Dermatol.

198 1:8: 160-161

Jacobs AH. Eruptions in the diaper area.

Pediatr Cliii North Am. 1978:25:209-224

Johns AM, Bower BD. Wasting of napkin area

after repeated use of fluorinated steroid

ointment. Br Med J. 1970; 1:347-348

Jordan WE, Lawson KD, Berg RW, et al.

Diaper dermatitis: frequency and severity

among a general infant population. PediatrDermatol. 1986;3: 198 -207

Koblenzer PJ. Diaper dermatitis: an overview.

Clin Pediatr. 1973:12:386-392

Leibovitz E, Orlow 5, Lawrence R, et al.

Children of Romania: the AIDS legacy.

Children s Hospital Quarterls’. I 99 1;3Leyden JJ, Kligman AM. The role of micro-

organisms in diaper dermatitis. Arch

Dermatol. 1978;I 14:56-59

Longhi F, Carlucci G, Bellucci R, et al. Diaper

dermatitis: a study of contributing factors.

Contact Dermatitis. I 992:26:248 -252

Rebora A, Leyden JJ. Napkin (diaper)

dermatitis and gastrointestinal carriage of

Candida albicans. Br J Dermatol. 1981:105:

55 1-555Thiboutot DM, Beckford A, Mart CR, et al.

Cytomegalovirus diaper dermatitis. ArchDermatol. 199 1 ; 127:296-298

Wong LD, Brantly D. Clutter LB, et al.

Diapering choices: a critical review of the

issues. Pediatr Nursing. 1992:18:41-54

INFECTIOUS DISEASEEndocarditis

*Ini�l pediatric doses are as follows: ampicillin, 50 mg/kg; amoxicillin, 50 mg/kg; genta-

micin, 2.0 mg/kg; and vancomycin, 20 mg/kg. Follow-up doses should be halfthe initialdose. Total pediatric dose should not exceed total adult dose.

PIR QUIZ

24. Antibiotic prophylaxis is not rec-

ommended for the pediatric patient

who has:

A. Aortic stenosis.

B. Atrial septal defect, secundum.

C. Coarctation of the aorta.

D. Patent ductus arteriosus.

E. Ventricular septal defect.

25. The antibiotic of choice for pro-

phylaxis during dental, oral, or up-

per respiratory tract procedures in

patients who are at risk is:

A. Ampicillin.

B. Cefaclor.C. Chloramphenicol.

D. Penicillin.

E. Vancomycin.

26. Which of the following is not a

feature of subacute bacterial endo-

carditis?

A. Anemia.B. Early cardiac decompensation.

C. Fever.D. Night sweats.

E. Weight loss.

27. The most diagnostic cardiac study

that every patient who has subacute

bacterial endocarditis should haveis:

A. Chest radiograph. posteroante-

nor and lateral.

B. Cineangiocardiography.

C. Echocardiogram.D. Electrocardiogram.

E. Hemodynamic cardiac catheter-

ization study.

28. The ultimate labcratory test findingto make the diagnosis of subacute

bacterial endocarditis is:

A. Abnormal electrocardiogram.B. Decreased hemoglobin.

C. Elevated erythrocyte sedimenta-

tiofl rate.

D. Elevated white blood count.

E. Positive blood culture.

SUGGESTED READINGDajani AD. Bisno AL, Chung KJ, et al.

Prevention of bacterial endocarditis:

recommendations by the American Heart

Association’s Committee on Rheumatic

Fever, Endocarditis, and Kawasaki Disease

of the Council on Cardiovascular Disease in

the Young. JAMA. 1990:264:2919-2922

Friedman RA, Starke JR. Infective endo-

carditis. In: Garson A Jr. Brickman iT,

McNamara DG, eds. The Science and

Practice of Pediatric Cardiology. Vol II.

Malvern, Penn: Lea & Febiger; 1990:1561-

I 576

Hoffman JIE. Infective endocarditis. In:

Rudolph AM. ed. Pediatrics. Norwalk,

Conn: Appleton & Lange: 1987:1326-1329

Korzeniowski OM. Kaye D. Infective

endocarditis. In: Braunwald E, ed. HeartDisease. WB Saunders Co: Philadelphia,

Penn: 1992:1078-I 105

MacMahon ST. Hickey AJ, Wilcken DEL, et

al. Risk of infective endocarditis in mitral

valve prolapse with and without precordial

systolic murmurs. A,n J (‘ardiol. 1987:59:

105- 108

154 Pediatrics iii Review Vol. 16 No. 4 April /995

TABLE 7. Regimens for Genitourinary/GastrointestinalProcedures: Infective Endocarditis Prophylaxis

DRUG DOSAGE REGIMEN*

Standard RegimenAmpicilbin, gentamicin, IV or IM administration of ampicillin 2.0 g

and amoxicillin plus gentamicin I .5 mg/kg (not to exceed80 mg) 30 mm before procedure,followed by amoxiciblin I .5 g orally 6 hafter initial dose; alternatively, theparenteral regimen may be repeated once8 h after initial dose

Ampicillin/Amoxicillin/Penicillin-allergic Patient RegimenVancomycin and IV administration of vancomycin 1 .0 g over

gentamicin 1 h plus IV or IM administration of

gentamicin 1 .5 mg/kg (not to exceed80 mg) I h before procedure; may berepeated once 8 h after initial dose

Alternate Low-risk PAmoxicillin

atient Regimen3.0 g orally 1 h before procedure, then

1 .5 g 6 h after initial dose