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 2020 Nelson’s Pediatric Antimicrobial Therapy
1. Choosing Among Antibiotics Within a Class: Beta-lactams and Beta-lactamase Inhibitors, Macrolides,

2020 Nelson’s Pediatric Antimicrobial Therapy

­Aminoglycosides, and Fluoroquinolones
2. Choosing Among Antifungal Agents: Polyenes, Azoles, and Echinocandins

3. How Antibiotic Dosages Are Determined Using Susceptibility Data, Pharmacodynamics, and Treatment Outcomes

4. Approach to Antibiotic Therapy of Drug-Resistant Gram-negative Bacilli and Methicillin-Resistant

­Staphylococcus ­aureus
5. Antimicrobial Therapy for Newborns

6. Antimicrobial Therapy According to Clinical Syndromes

2020
7. Preferred Therapy for Specific Bacterial and Mycobacterial Pathogens
Nelson’s Pediatric
8. Preferred Therapy for Specific Fungal Pathogens Antimicrobial Therapy
9. Preferred Therapy for Specific Viral Pathogens 26th Edition
John S. Bradley, MD
10. Preferred Therapy for Specific Parasitic Pathogens Editor in Chief

11. Alphabetic Listing of Antimicrobials John D. Nelson, MD

Emeritus
12. Antibiotic Therapy for Children Who Are Obese

26th Edition
Elizabeth D. Barnett, MD
13. Sequential Parenteral-Oral Antibiotic Therapy (Oral Step-down Therapy) for Serious Infections Joseph B. Cantey, MD
14. Antimicrobial Prophylaxis/Prevention of Symptomatic Infection
David W. Kimberlin, MD
Paul E. Palumbo, MD
Appendix: Nomogram for Determining Body Surface Area Nelson Jason Sauberan, PharmD
Bradley J. Howard Smart, MD
References
William J. Steinbach, MD
Index Contributing Editors

ISBN 978-1-61002-352-8
90000>

9 781610 023528 AAP

NELSON-2020_CoverSpread.indd 1 11/22/19 3:05 PM

 American Academy of Pediatrics Publishing Staff
Mary Lou White, Chief Product and Services Officer/SVP, Membership, Marketing, and Publishing
Mark Grimes, Vice President, Publishing
Peter Lynch, Senior Manager, Publishing Acquisitions and Digital Strategy
Mary Kelly, Senior Editor, Professional and Clinical Publishing
Shannan Martin, Production Manager, Consumer Publications
Jason Crase, Manager, Editorial Services
Linda Smessaert, MSIMC, Senior Marketing Manager, Professional Resources
Mary Louise Carr, MBA, Marketing Manager, Clinical Publications
Published by the American Academy of Pediatrics
345 Park Blvd
Itasca, IL 60143
Telephone: 630/626-6000
Facsimile: 847/434-8000
www.aap.org
The American Academy of Pediatrics is an organization of 67,000 primary care pediatricians, pediatric medical
subspecialists, and pediatric surgical specialists dedicated to the health, safety, and well-being of infants,
children, adolescents, and young adults.
The recommendations in this publication do not indicate an exclusive course of treatment or serve as a
standard of medical care. Variations, taking into account individual circumstances, may be appropriate.
Statements and opinions expressed are those of the authors and not necessarily those of the
American Academy of Pediatrics.
Any websites, brand names, products, or manufacturers are mentioned for informational and identification
purposes only and do not imply an endorsement by the American Academy of Pediatrics (AAP). The AAP is not
responsible for the content of external resources. Information was current at the time of publication.
The publishers have made every effort to trace the copyright holders for borrowed materials.
If they have inadvertently overlooked any, they will be pleased to make the necessary
arrangements at the first opportunity.
This publication has been developed by the American Academy of Pediatrics. The authors, editors, and
contributors are expert authorities in the field of pediatrics. No commercial involvement of any kind has
been solicited or accepted in the development of the content of this publication. Disclosures: Dr Kimberlin
disclosed a consulting relationship with Slack Incorporated. Dr Palumbo disclosed a safety monitoring
board relationship with Janssen Pharmaceutical Companies. Dr Steinbach disclosed an advisory board
relationship with Merck & Company and Astellas Pharma, Inc.
Every effort has been made to ensure that the drug selection and dosages set forth in this text are in
accordance with current recommendations and practice at the time of publication. It is the responsibility of
the health care professional to check the package insert of each drug for any change in indications or
dosage and for added warnings and precautions, and to review newly published, peer-reviewed data in
the medical literature for current data on safety and efficacy.
Special discounts are available for bulk purchases of this publication.
Email Special Sales at [email protected] for more information.
© 2020 John S. Bradley and John D. Nelson
Publishing rights, American Academy of Pediatrics. All rights reserved. No part of this publication may be
reproduced, stored in a retrieval system, or transmitted in any form or by any means—electronic, mechanical,
photocopying, recording, or otherwise—without prior permission from the authors.
First edition published in 1975.
Printed in the United States of America.
9-442/1219     1 2 3 4 5 6 7 8 9 10
MA0935
ISSN: 2164-9278 (print)
ISSN: 2164-9286 (electronic)
ISBN: 978-1-61002-352-8
eBook: 978-1-61002-353-5

ch00-Nelson-2020_FM_i-xii.indd 2 11/21/19 8:17 AM

 iii
Editor in Chief Emeritus
John S. Bradley, MD, FAAP John D. Nelson, MD
Distinguished Professor of Pediatrics Professor Emeritus of Pediatrics
Division of Infectious Diseases, Department of The University of Texas
Pediatrics Southwestern Medical Center at Dallas
University of California, San Diego, Southwestern Medical School
School of Medicine Dallas, TX
Director, Division of Infectious Diseases,
Rady Children’s Hospital San Diego
San Diego, CA
Chapters 1, 3, 4, 6, 7, 13, and 14

Contributing Editors
Elizabeth D. Barnett, MD, FAAP Jason Sauberan, PharmD
Professor of Pediatrics Assistant Clinical Professor
Boston University School of Medicine University of California, San Diego,
Director, International Clinic and Refugee Health Skaggs School of Pharmacy and Pharmaceutical
Assessment Program, Boston Medical Center Sciences
GeoSentinel Surveillance Network, Rady Children’s Hospital San Diego
Boston Medical Center San Diego, CA
Boston, MA Chapters 5, 11, and 12
Chapter 10
J. Howard Smart, MD, FAAP
Joseph B. Cantey, MD, FAAP Chairman, Department of Pediatrics
Assistant Professor of Pediatrics Sharp Rees-Stealy Medical Group
Divisions of Pediatric Infectious Diseases and Assistant Clinical Professor of Pediatrics
Neonatology/Perinatal Medicine University of California, San Diego,
University of Texas Health Science Center at School of Medicine
San Antonio San Diego, CA
San Antonio, TX App development
Chapter 5
William J. Steinbach, MD, FAAP
David W. Kimberlin, MD, FAAP Samuel L. Katz Professor of Pediatrics
Editor, Red Book: 2018–2021 Report of the Committee Professor in Molecular Genetics and Microbiology
on Infectious Diseases, 31st Edition Chief, Division of Pediatric Infectious Diseases
Professor of Pediatrics Director, Duke Pediatric Immunocompromised Host
Co-Director, Division of Pediatric Infectious Diseases Program
Sergio Stagno Endowed Chair in Director, International Pediatric Fungal Network
Pediatric Infectious Diseases Duke University School of Medicine
University of Alabama at Birmingham Durham, NC
Birmingham, AL Chapters 2 and 8
Chapter 9
Paul E. Palumbo, MD
Professor of Pediatrics and Medicine
Geisel School of Medicine at Dartmouth
Director, International Pediatric HIV Program
Dartmouth-Hitchcock Medical Center
Lebanon, NH
HIV treatment

ch00-Nelson-2020_FM_i-xii.indd 3 11/21/19 8:17 AM

ch00-Nelson-2020_FM_i-xii.indd 4 11/21/19 8:17 AM
 v

Contents

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii
Notable Changes to 2020 Nelson’s Pediatric Antimicrobial Therapy,
26th Edition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi
1. Choosing Among Antibiotics Within a Class: Beta-lactams and Beta-lactamase
Inhibitors, Macrolides, Aminoglycosides, and Fluoroquinolones . . . . . . . . . . . . . . . . . . . 1
2. Choosing Among Antifungal Agents: Polyenes, Azoles, and Echinocandins. . . . . . 9
3. How Antibiotic Dosages Are Determined Using Susceptibility Data,
Pharmacodynamics, and Treatment Outcomes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
4. Approach to Antibiotic Therapy of Drug-Resistant Gram-negative Bacilli
and Methicillin-Resistant Staphylococcus aureus. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
5. Antimicrobial Therapy for Newborns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
A. Recommended Therapy for Selected Newborn Conditions. . . . . . . . . . . . . . . . . . . . . . . . 33
B. Antimicrobial Dosages for Neonates. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
C. Aminoglycosides. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
D. Vancomycin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
E. Use of Antimicrobials During Pregnancy or Breastfeeding . . . . . . . . . . . . . . . . . . . . . . . . 60
6. Antimicrobial Therapy According to Clinical Syndromes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
A. Skin and Soft Tissue Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
B. Skeletal Infections. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
C. Eye Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
D. Ear and Sinus Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
E. Oropharyngeal Infections. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
F. Lower Respiratory Tract Infections. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
G. Cardiovascular Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
H. Gastrointestinal Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .105
I. Genital and Sexually Transmitted Infections. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
J. Central Nervous System Infections. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116
K. Urinary Tract Infections. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
L. Miscellaneous Systemic Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
7. Preferred Therapy for Specific Bacterial and Mycobacterial Pathogens. . . . . . . . .131
A. Common Bacterial Pathogens and Usual Pattern of Susceptibility to
Antibiotics (Gram Positive). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132
B. Common Bacterial Pathogens and Usual Pattern of Susceptibility to
Antibiotics (Gram Negative). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134
C. Common Bacterial Pathogens and Usual Pattern of Susceptibility to
Antibiotics (Anaerobes) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .136
D. Preferred Therapy for Specific Bacterial and Mycobacterial Pathogens. . . . . . . . 138

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 vi — Contents

8. Preferred Therapy for Specific Fungal Pathogens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159

A. Overview of More Common Fungal Pathogens and Their Usual Pattern
of Antifungal Susceptibilities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160
B. Systemic Infections. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162
C. Localized Mucocutaneous Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .176
9. Preferred Therapy for Specific Viral Pathogens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177
A. Overview of Non-HIV, Non-Hepatitis B or C Viral Pathogens and
Usual Pattern of Susceptibility to Antivirals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178
B. Overview of Hepatitis B or C Viral Pathogens and Usual Pattern of
Susceptibility to Antivirals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .178
C. Preferred Therapy for Specific Viral Pathogens. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .180
10. Preferred Therapy for Specific Parasitic Pathogens. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195
A. Selected Common Pathogenic Parasites and Suggested
Agents for Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 196
B. Preferred Therapy for Specific Parasitic Pathogens. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .198
11. Alphabetic Listing of Antimicrobials. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219
A. Systemic Antimicrobials With Dosage Forms and Usual Dosages. . . . . . . . . . . . . . . 221
B. Topical Antimicrobials (Skin, Eye, Ear, Mucosa) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 244
12. Antibiotic Therapy for Children Who Are Obese . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .251
13. Sequential Parenteral-Oral Antibiotic Therapy (Oral Step-down Therapy)
for Serious Infections. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .255
14. Antimicrobial Prophylaxis/Prevention of Symptomatic Infection . . . . . . . . . . . . . . . 257
A. Postexposure Antimicrobial Prophylaxis to Prevent Infection. . . . . . . . . . . . . . . . . . . 259
B. Long-term Antimicrobial Prophylaxis to Prevent Symptomatic
New Infection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .265
C. Prophylaxis of Symptomatic Disease in Children Who Have Asymptomatic
Infection/Latent Infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 266
D. Surgical/Procedure Prophylaxis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .269
Appendix: Nomogram for Determining Body Surface Area. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 275
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .277
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 301

ch00-Nelson-2020_FM_i-xii.indd 6 11/21/19 8:17 AM

 vii

Introduction
Hard to believe, but we are now in our 26th edition of Nelson’s Pediatric Antimicrobial
Therapy—and more than a decade with the American Academy of Pediatrics (AAP)!
We had the incredible opportunity late last year to publicly thank John Nelson for his
many contributions to the field of pediatric infectious diseases over his decades-long
career, including his creation of the Pocket Book of Pediatric Antimicrobial Therapy,
which was the predecessor of Nelson’s and the model for the Sanford guide for adults.
Clinicians did not have so many options for antibiotic therapy when he was first
­recruited to Dallas, where he recruited George McCracken to join him. We have trained
John on the iPhone app for his book, but he still prefers the printed version. We are
working with the AAP to further enhance the ability of clinicians to access treatment
recommendations easily and allow us to bring important new advances in the field of
pediatric anti-infective therapy more often than once yearly.
A number of new antibiotics, antivirals, and antifungals have been recently approved by
the US Food and Drug Administration (FDA) for pediatric age groups and are high-
lighted in the Notable Changes. Some new agents only have approvals for children
12 years and older, but virtually all have federal mandates for clinical trials through all
pediatric age groups, including neonates. Most of the newly approved antibacterial
agents are for drug-resistant pathogens, not for pneumococcus or Haemophilus influen-
zae type b, given the spectacular success of the protein-conjugated vaccines. For the
community, Escherichia coli is now giving us headaches with increasing resistance; for
hospital pathogens, everything is getting more resistant.
The contributing editors, all very active in clinical work, have updates in their sections
with relevant new recommendations (beyond FDA approvals) based on current pub-
lished data, guidelines, and clinical experience. We believe that the reference list for each
chapter provides the available evidence to support our recommendations, for those who
wish to see the actual clinical trial and in vitro data.
The Nelson’s app has made significant advances this past year thanks to the Apple
­programing abilities of our contributing editor, Dr Howard Smart, a full-time office-
based pediatrician and the chief of pediatrics at the Sharp Rees-Stealy multispecialty
medical group in San Diego, CA. With the support of the AAP (particularly Peter
Lynch) and the editors, we are putting even more of Howard’s enhancements in this
2020 edition. I use the app during rounds now, and we have provided the app to all our
residents. There are clear advantages to the app over the printed book, but as with all
software, glitches may pop up, so if your app doesn’t work, please let us know at
[email protected] so we can fix the bugs!

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 viii — Introduction

We always appreciate the talent and advice of our collaborators/colleagues who take the
time to see if what we are sharing “makes sense.” In particular, we wish to thank Drs
John van den Anker and Pablo Sanchez for their valuable suggestions on antimicrobial
therapy of the newborn in support of the work done by JB Cantey and Jason Sauberan in
Chapter 5.
We are also fortunate to have 3 reviewers for the entire book and app this year.
Returning to assist us is Dr Brian Williams, a pediatric/adult hospitalist who recently
moved from San Diego to Madison, WI. Brian’s suggestions are always focused and
practical, traits that John Nelson specifically values and promotes. New for this year, to
help us with the user experience of the app, we welcome input from Dr Juan Chapparro,
who is double boarded in pediatric infectious diseases and biomedical informatics, and
Dr Daniel Sklansky, a pediatric hospitalist at the University of Wisconsin.
We continue to harmonize the Nelson’s book with Red Book: 2018–2021 Report of the
Committee on Infectious Diseases, 31st Edition (easy to understand, given that Dr David
Kimberlin is also the editor of the Red Book). We are virtually always in sync but often
with additional explanations (that do not necessarily represent AAP policy) to allow the
reader to understand the basis for recommendations.
We continue to provide grading of our recommendations—our assessment of how
strongly we feel about a recommendation and the strength of the evidence to support
our recommendation (noted in the Table). This is not the GRADE method (Grading of
Recommendations Assessment, Development, and Evaluation) but certainly uses the
concepts on which GRADE is based: the strength of recommendation and level of evi-
dence. Similar to GRADE, we review the literature (and the most important manuscripts
are referenced), but importantly, we work within the context of professional society rec-
ommendations (eg, the AAP) and our experience. The data may never have been pre-
sented to or reviewed by the FDA and, therefore, are not in the package label. We all
find ourselves in this situation frequently. Many of us are working closely with the FDA
to try to narrow the gap in our knowledge of antimicrobial agents between adults and
children; the FDA pediatric infectious diseases staff is providing an exceptional effort to
shed light on the doses that are safe and effective for neonates, infants, and children,
with major efforts, supported by grants from the Eunice Kennedy Shriver National
Institute of Child Health and Human Development (with Dr Danny Benjamin from
Duke leading the charge), to place important new data on safety and efficacy in the anti-
biotic package labels for all to use in clinical practice.

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 Introduction — ix

Strength of Recommendation Description

A Strongly recommended
B Recommended as a good choice
C One option for therapy that is adequate, perhaps among
many other adequate therapies
Level of Evidence Description
I Based on well-designed, prospective, randomized,
and controlled studies in an appropriate population
of children
II Based on data derived from prospectively collected,
small comparative trials, or noncomparative
prospective trials, or reasonable retrospective data
from clinical trials in children, or data from other
populations (eg, adults)
III Based on case reports, case series, consensus
statements, or expert opinion for situations in
which sound data do not exist

As we state each year, many of the recommendations by the editors for specific situa-
tions have not been systematically evaluated in controlled, prospective, comparative
clinical trials.
Mary Kelly, our senior editor at the AAP, has done an impressive job organizing the edi-
tors and being an outstanding advocate for us and the clinician-users of the book. She
was also instrumental in helping to launch the Nelson’s Neonatal Antimicrobial Therapy
manual in spring 2019.
Peter Lynch (AAP senior manager, publishing acquisitions and digital strategy) continues
to work on developing Nelson’s online, as well as working with Howard and the editors to
enhance the functionality of the app. Thanks to Mark Grimes, vice president, Publishing,
and our steadfast friends and supporters in AAP Membership, Marketing, and
Publishing—Jeff Mahony, director, professional and consumer publishing (who has been
with us since we first joined with the AAP a decade ago); Linda Smessaert, senior market-
ing manager, professional resources; and the entire staff—who make certain that the con-
siderable information in Nelson’s makes it to those who are actually caring for children.
We continue to be very interested to learn from readers/users if there are new chapters
or sections you wish for us to develop—and whether you find certain sections particu-
larly helpful, so we don’t change or delete them! Please feel free to share your sugges-
tions with us at [email protected].
John S. Bradley, MD

ch00-Nelson-2020_FM_i-xii.indd 9 11/21/19 8:17 AM

ch00-Nelson-2020_FM_i-xii.indd 10 11/21/19 8:17 AM
 xi

Notable Changes to 2020 Nelson’s Pediatric Antimicrobial Therapy, 26th Edition

References have been updated, with more than 150 new references. Based on comments
we received, we now have the supporting references in the app that are as easily accessible
as in the book; we are quite grateful to our contributing editor, Dr Howard Smart, for
entering every reference by hand (nearly 400 references for Chapter 6 alone) and writing
the code so that both the references and the abstracts from PubMed are now just a few
taps away on your screen. Just amazing.
Bacterial/Mycobacterial Infections and Antibiotics
We were quite disappointed that cefotaxime is no longer being manufactured for the US
market. This was one of the first of the third-generation cephalosporins that was docu-
mented to be safe and effective for many infections (including meningitis) in all pediatric
age groups, including the neonate, caused by a wide variety of susceptible pathogens.
Because it is not available, we have removed it from all our recommendations (including
neonates), but we hope that someone will manufacture it again in the future. For older
children, ceftriaxone should continue to work well, but for neonates, it is the consensus
opinion of the editors that cefepime now be substituted in situations where you would
have previously used cefotaxime, based on its gram-positive and enteric bacilli spectrum
and pharmacokinetic profile, which is very similar to cefotaxime. Effectiveness in pedi-
atric meningitis was demonstrated by one of John Nelson’s previous pediatric infectious
disease fellows, Xavier Saez-Llorens. The broader spectrum of meropenem is not needed
for neonatal sepsis in 2020.
We are now shifting our recommendation for serious, invasive methicillin-resistant
Staphylococcus aureus (MRSA) infections from vancomycin to ceftaroline for several rea-
sons, primarily safety and more predictable efficacy for MRSA, although we are holding
off recommendations for MRSA endocarditis and central nervous system infections, as
the US companies that have owned the antibiotic (Cerexa/Forest/Actavis/Allergan) have
not supported prospective pediatric clinical trials for these indications.
Updates for gastrointestinal pathogen infections (including traveler’s diarrhea) from the
new Infectious Diseases Society of America guidelines have now been incorporated.
For children with latent tuberculosis, we support once-weekly isoniazid and rifapentine
for 12 weeks as the preferred regimen, given data on improved compliance.
Ceftazidime/avibactam was approved for pediatrics by the US Food and Drug Adminis-
tration (FDA) in March 2019 and has activity against extended-spectrum beta-lactamase
Escherichia coli as well as carbapenem-resistant Klebsiella pneumoniae carbapenemase–
bearing strains of E coli and Klebsiella.

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 xii — Notable Changes to 2020 Nelson’s Pediatric Antimocrobial Therapy, 26th Edition

Fungal Infections and Antifungal Agents

New approaches to mucormycosis, a devastating infection, have been added, based on
published data, animal models, and the extensive experience of William J. Steinbach, MD,
whom we all call for advice.
New references on dosing fluconazole and anidulafungin for invasive candidiasis have
been added.
Viral Infections and Antiviral Agents
Just want to remind everyone that current recommendations about HIV and antiretrovi-
rals, including those for the management of newborns exposed to HIV, are posted on the
AIDSinfo website (https://aidsinfo.nih.gov), which is continuously updated.
Baloxavir, an influenza antiviral, was approved for adults and children older than 12 years
for outpatient management of uncomplicated influenza in otherwise healthy patients (just
a single dose). This antiviral has a completely different mechanism of action against influ-
enza, compared with oseltamivir, zanamivir, and peramivir, as it blocks early initiation
of influenza virus nucleic acid replication. There are no data in the United States yet for
younger children, although it is approved in Japan for children down to 2 years of age.
Parasitic Infections and Antiparasitic Agents
Intravenous (IV) quinidine is no longer an option for treatment for severe malaria, with
IV artesunate, available from the Centers for Disease Control and Prevention, as the only
remaining option.
Tafenoquine is now available for prophylaxis and treatment of malaria.
Triclabendazole is now approved by the FDA for treatment of fascioliasis in those 6 years
and older.

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 2020 Nelson’s Pediatric Antimicrobial Therapy — 1

1. Choosing Among Antibiotics Within a Class: Beta-lactams and 1

Beta-lactamase Inhibitors, Macrolides, Aminoglycosides, and

Choosing Among Antibiotics Within a Class: Beta-lactams and Beta-lactamase Inhibitors, Macrolides, Aminoglycosides, and Fluoroquinolones
Fluoroquinolones
New drugs should be compared with others in the same class regarding (1) antimicrobial
spectrum; (2) degree of antibiotic exposure (a function of the pharmacokinetics of the
nonprotein-bound drug at the site of infection and the pharmacodynamic properties
of the drug); (3) demonstrated efficacy in adequate and well-controlled clinical trials;
(4) tolerance, toxicity, and side effects; and (5) cost. If there is no substantial benefit for
efficacy or safety for one antimicrobial over another for the isolated or presumed bacte-
rial pathogen(s), one should opt for using an older, more extensively used agent (with
presumably better-defined efficacy and safety) that is usually less expensive and preferably
with a narrower spectrum of activity.
Beta-lactams and Beta-lactamase Inhibitors
Beta-lactam (BL)/Beta-lactamase Inhibitor (BLI) Combinations. Increasingly studied
and approved by the US Food and Drug Administration (FDA) are BL/BLI combinations
that target antibiotic resistance based on the presence of a pathogen’s beta-lactamase. The
BL antibiotic may demonstrate activity against a pathogen, but if a beta-lactamase is pres-
ent in that pathogen, it will hydrolyze the BL ring structure and inactivate the antibiotic.
The BLI is usually a BL structure, which explains why it binds readily to certain beta-
lactamases and can inhibit their activity; however, the BLI usually does not demonstrate
direct antibiotic activity itself. As amoxicillin and ampicillin were used extensively against
Haemophilus influenzae following their approval, resistance increased based on the pres-
ence of a beta-lactamase that hydrolyzes the BL ring of amoxicillin/ampicillin (with up to
40% of isolates demonstrating resistance in some regions). Clavulanate, a BLI that binds
to and inactivates the H influenzae beta-lactamase, allows amoxicillin/ampicillin to “sur-
vive” and inhibit cell wall formation, leading to the death of the organism. The first oral
BL/BLI combination of amoxicillin/clavulanate, originally known as Augmentin, has been
very effective. Similar combinations, primarily intravenous (IV), have now been studied,
pairing penicillins, cephalosporins, and carbapenems with other BLIs such as tazobactam,
sulbactam, and avibactam. Under investigation in children are the IV BL/BLI combina-
tions meropenem/vaborbactam, ceftolozane/tazobactam, and imipenem/relebactam.
Beta-lactam Antibiotics
Oral Cephalosporins (cephalexin, cefadroxil, cefaclor, cefprozil, cefuroxime, cefix-
ime, cefdinir, cefpodoxime, cefditoren [tablet only], and ceftibuten). As a class, the oral
cephalosporins have the advantage over oral penicillins of somewhat greater spectrum of
activity. The serum half-lives of cefpodoxime, ceftibuten, and cefixime are greater than
2 hours. This pharmacokinetic feature accounts for the fact that they may be given in
1 or 2 doses per day for certain indications, particularly otitis media, where the middle
ear fluid half-life is likely to be much longer than the serum half-life. For more resistant
pathogens, twice daily is preferred (see Chapter 3). The spectrum of activity increases
for gram-negative organisms as one goes from the first-generation cephalosporins

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 2 — Chapter 1. Choosing Among Antibiotics Within a Class: Beta-lactams and Beta-lactamase
Inhibitors, Macrolides, Aminoglycosides, and Fluoroquinolones

1 (­cephalexin and cefadroxil), to the second generation (cefaclor, cefprozil, and cefuroxime)
that demonstrates activity against H influenzae (including beta-lactamase–producing
Choosing Among Antibiotics Within a Class: Beta-lactams and Beta-lactamase Inhibitors, Macrolides, Aminoglycosides, and Fluoroquinolones

strains), to the third-generation agents (cefdinir, cefixime, cefpodoxime, and ceftibuten)

that have enhanced coverage of many enteric gram-negative bacilli (Escherichia coli,
Klebsiella spp). However, ceftibuten and cefixime, in particular, have a disadvantage
of less activity against Streptococcus pneumoniae than the others, particularly against
penicillin non-susceptible strains. No oral fourth- or fifth-generation cephalosporins (see
the Parenteral Cephalosporins section) currently exist (ie, no oral cephalosporins with
activity against Pseudomonas or methicillin-resistant Staphylococcus aureus [MRSA]).
The palatability of generic versions of these products may not have the same better-tasting
characteristics as the original products.
Parenteral Cephalosporins. First-generation cephalosporins, such as cefazolin, are used
mainly for treatment of gram-positive infections caused by S aureus (excluding MRSA)
and group A streptococcus and for surgical prophylaxis; the gram-negative spectrum is
limited but more extensive than ampicillin. Cefazolin is well tolerated on intramuscular
or IV injection.
A second-generation cephalosporin (cefuroxime) and the cephamycins (cefoxitin and
cefotetan) provide increased activity against many gram-negative organisms, particularly
H influenzae and E coli. Cefoxitin has, in addition, activity against only 80% of strains of
Bacteroides fragilis but can be considered for use in place of the more active agents like
metronidazole or carbapenems when beta-lactamase–positive Bacteroides and Prevotella
spp are suspected, and up to 20% treatment failure is acceptable.
Third-generation cephalosporins (cefotaxime, ceftriaxone, and ceftazidime) all have
enhanced potency against many enteric gram-negative bacilli. As with all cephalosporins
at readily achievable serum concentrations, they are less active against enterococci and
Listeria; only ceftazidime has significant activity against Pseudomonas. Cefotaxime (cur-
rently not being manufactured) and ceftriaxone have been used very successfully to treat
meningitis caused by pneumococcus (mostly penicillin-susceptible strains), H influenzae
type b, meningococcus, and susceptible strains of E coli meningitis. These drugs have
the greatest usefulness for treating gram-negative bacillary infections due to their safety,
compared with other classes of antibiotics (including aminoglycosides). Because ceftriax-
one is excreted to a large extent via the liver, it can be used with little dosage adjustment
in patients with renal failure. With a serum half-life of 4 to 7 hours, it can be given once a
day for all infections, including meningitis, that are caused by susceptible organisms.
Cefepime, a fourth-generation cephalosporin approved for use in children in 1999,
exhibits (1) enhanced antipseudomonal activity over ceftazidime; (2) the gram-positive
activity of second-generation cephalosporins; (3) better activity against gram-negative
enteric bacilli; and (4) stability against the inducible ampC beta-lactamases of Entero-
bacter and Serratia (and some strains of Proteus and Citrobacter) that can hydrolyze
third-generation cephalosporins. It can be used as single-drug antibiotic therapy against
these pathogens, rather than paired with an aminoglycoside, as is commonly done with

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 2020 Nelson’s Pediatric Antimicrobial Therapy — 3

third-generation cephalosporins to decrease the emergence of ampC-resistant strains. 1

In general, cefepime is hydrolyzed by many of the newly emergent extended-spectrum

Choosing Among Antibiotics Within a Class: Beta-lactams and Beta-lactamase Inhibitors, Macrolides, Aminoglycosides, and Fluoroquinolones
beta-lactamase (ESBL) enzymes and should not be used if an ESBL E coli or Klebsiella is
suspected.
Ceftaroline is a fifth-generation cephalosporin, the first of the cephalosporins with activ-
ity against MRSA. Ceftaroline was approved by the FDA in December 2010 for adults
and approved for children in June 2016 for treatment of complicated skin infections
(including MRSA) and community-acquired pneumonia. The pharmacokinetics of cef-
taroline have been evaluated in all pediatric age groups, including neonates and children
with cystic fibrosis; clinical studies for pediatric community-acquired pneumonia and
complicated skin infection are published.1,2 Based on these published data, review by the
FDA, and post-marketing experience for infants and children 2 months and older, we
believe that ceftaroline should be as effective and safer than vancomycin for treatment of
MRSA infections. Just as BLs like cefazolin are preferred over vancomycin for methicillin-
susceptible S aureus infections, ceftaroline should be considered preferred treatment
over vancomycin for MRSA infection. Neither renal function nor drug levels need to be
followed with ceftaroline therapy. Limited pharmacokinetic and clinical data also support
the use of ceftaroline in neonates.
Penicillinase-Resistant Penicillins (dicloxacillin [capsules only]; nafcillin and oxacillin
[parenteral only]). “Penicillinase” refers specifically to the beta-lactamase produced by
S aureus in this case and not those produced by gram-negative bacteria. These antibiot-
ics are active against penicillin-resistant S aureus but not against MRSA. Nafcillin differs
pharmacologically from the others in being excreted primarily by the liver rather than
by the kidneys, which may explain the relative lack of nephrotoxicity compared with
methicillin, which is no longer available in the United States. Nafcillin pharmacokinetics
are erratic in persons with liver disease, and the drug is often painful with IV infusion.
Antipseudomonal and Anti-enteric Gram-negative BLs (piperacillin/tazobactam,
aztreonam, ceftazidime, cefepime, meropenem, and imipenem). Piperacillin/tazobactam
(Zosyn) and ceftazidime/avibactam (Avycaz) (both FDA approved for children), and
still under investigation in children, ceftolozane/tazobactam (Zerbaxa) and meropenem/
vaborbactam (Vabomere), represent BL/BLI combinations, as noted previously. The
BLI (clavulanic acid, tazobactam, avibactam, or vaborbactam in these combinations)
binds irreversibly to and neutralizes specific beta-lactamase enzymes produced by the
organism. The combination only adds to the spectrum of the original antibiotic when the
mechanism of resistance is a beta-lactamase enzyme and only when the BLI is capable
of binding to and inhibiting that particular organism’s beta-lactamase enzyme(s). The
combinations extend the spectrum of activity of the primary antibiotic to include many
beta-lactamase–positive bacteria, including some strains of enteric gram-negative bacilli
(E coli, Klebsiella, and Enterobacter), S aureus, and B fragilis. Piperacillin/tazobac-
tam, ceftolozane/tazobactam, and ceftazidime/avibactam may still be inactive against
Pseudomonas because their BLIs may not effectively inhibit all of the beta-lactamases of
Pseudomonas, and other mechanisms of resistance may also be present.

ch01-Nelson-2020_001-008.indd 3 11/14/19 8:02 AM

Random documents with unrelated
content Scribd suggests to you:
 The Dog sued the Sheep for a debt, of which the Kite and the
Wolf were to be judges. They, without debating long upon the
matter, or making any scruple for want of evidence, gave sentence
for the plaintiff; who immediately tore the poor Sheep in pieces, and
divided the spoil with the unjust judges.

Morals.

We cannot reasonably hope for justice in a court,

where the judges are interested in the decision.

Whose life is safe, if tried before a judge,

That to the hapless pris’ner bears a grudge?
Whose property secur’d from lawless fury,
If any private int’rest warps the jury?

Reflection.

Deplorable are the times, when open bare-faced villany is

protected and encouraged, when innocence is obnoxious, honesty
contemptible, and it is reckoned criminal to espouse the cause of
virtue. Men originally entered into covenants and simple compacts
with each other for the promotion of their happiness and well-being,
for the establishment of justice and public peace. How comes it then
that they look stupidly on, and tamely acquiesce, when wicked men
pervert this end, and establish an arbitrary tyranny of their own
upon the foundation of fraud and oppression? Among beasts, who
are incapable of being civilised by social laws, it is no strange thing
to see innocent helpless sheep fall a prey to dogs, wolves, and kites:
But it is amazing how mankind could ever sink down to such a low
degree of base cowardice, as to suffer some of the worst of their
species to usurp a power over them, to supersede the righteous
laws of good government, and to exercise all kinds of injustice and
hardship in gratifying their own vicious lusts. Wherever such
enormities are practised, it is when a few rapacious statesmen
combine together, to get and secure the power in their own hands,
and agree to divide the spoils among themselves. For as long as the
cause is to be tried only among themselves, no question but they
will always vouch for each other. But, at the same time, it is hard to
determine which resemble brutes most, they in acting, or the people
in suffering them to act their vile selfish schemes.

Fable LXII.
The Proud Frog.
An Ox, grazing in a meadow, chanced to set his foot among a
parcel of young frogs, and trod one of them to death. The rest
informed their mother, when she came home, what had happened;
telling her, that the beast which did it was the hugest creature that
ever they saw in their lives. What, was it so big? says the old Frog,
swelling and blowing up her speckled belly to a great degree. Oh,
bigger by a vast deal, say they. And so big? says she, straining
herself yet more. Indeed, Mamma, say they, if you were to burst
yourself, you would never be so big. She strove yet again, and burst
herself indeed.

Morals.

The silly ambition of vying with our superiors, in

station and fortune, is the direct road to ruin.

Ye cits! of narrow means and small estate,

View not with envy the luxurious great:
Think that from riot bankruptcies will come,
And mark your prudent neighbour worth a plum.

Reflection.

Whenever a man endeavours to live equal with one of a greater

fortune than himself, he is sure to share a like fate with the Frog in
the Fable. How many vain people of moderate easy circumstances
burst and come to nothing, by vying with those whose estates are
more ample than their own! Sir Changeling Plumbstock was
possessed of a very considerable demesne, devolved to him by the
death of an old uncle of the city, who had adopted him his heir. He
had a false taste of happiness; and, without the least economy,
trusting to the sufficiency of his vast revenue, was resolved to be
outdone by nobody, in shewish grandeur and expensive living. He
gave five thousand pounds for a piece of ground in the country, to
set a house upon, the building and furniture of which cost fifty
thousand more; and his gardens were proportionably magnificent.
Besides which, he thought himself under a necessity of buying out
two or three tenements which stood in his neighbourhood, that he
might have elbow room enough. All this he could very well bear; and
still might have been happy, had it not been for an unfortunate view
which he one day happened to take of my Lord Castlebuilder’s
gardens, which consist of twenty acres, whereas his own were not
above twelve. For from that time he grew pensive; and before the
ensuing winter, gave five and thirty years’ purchase for a dozen
acres more to enlarge his gardens, built a couple of exorbitant
greenhouses and a large pavilion at the farther end of a terrace
walk, the bare repairs and superintendencies of all which call for the
remaining part of his income. He is mortgaged pretty deep, and pays
nobody; but, being a privileged person, resides altogether at a
private cheap lodging in the city of Westminster.
 Fable LXIII.
The Dove and the Bee.
The Bee, compelled by thirst, went to drink in a clear purling
rivulet; but the current, with its circling eddy, snatched her away,
and carried her down the stream. A Dove, pitying her distressed
condition, cropt a branch from a neighbouring tree, and let it fall into
the water, by means of which the Bee saved herself, and got ashore.
Not long after, a Fowler, having a design upon the Dove, planted his
nets and all his little artillery in due order, without the Bird’s
observing what he was about; which the Bee perceiving, just as he
was going to put his design in execution she bit him by the heel, and
made him give so sudden a start, that the Dove took the alarm, and
flew away.

Morals.
 Charity will have its rewards one time or other; for
certain in the promised recompense hereafter, perhaps
in a grateful return here.

Hail gratitude! the spark whence virtue springs,

And adoration to the King of kings;
The greatest bliss the feeling bosom knows,
The source whence every gen’rous action flows.

Reflection.

One good turn deserves another; and gratitude is excited by so

noble and natural a spirit, that he ought to be looked upon as the
vilest of creatures, who has no sense of it. It is, indeed, so very just
and equitable a thing, and so much every man’s duty, that to speak
of it properly one should not mention it as anything meritorious, or
that may claim praise and admiration, any more than we should say
a man ought to be rewarded or commended for not killing his father,
or forbearing to set fire to his neighbour’s house. The bright and
shining piece of morality, therefore, which is recommended to us in
this Fable, is set forth in this example of the Dove, who, without any
obligation or expectation, does a voluntary office of charity to its
fellow-creature in distress. The constant uninterrupted practice of
this virtue is the only thing in which we are capable of imitating the
great Author of our being, whose Beloved Son, besides the many
precepts He has given to enforce this duty, used this expression as a
common saying, It is more blessed to give than to receive.
 Fable LXIV.
The Collier and the Fuller.
The Collier and the Fuller, being old acquaintance, happened upon
a time to meet together; and the latter, being but ill provided with a
habitation, was invited by the former to come and live in the same
house with him. I thank you, my dear friend, replies the Fuller, for
your kind offer, but it cannot be; for if I were to dwell with you,
whatever I should take pains to scour and make clean in the
morning, the dust of you and your coals would blacken and defile, as
bad as ever, before night.

Morals.

We commonly imbibe the principles and manners of

those with whom we associate.
 With vice allied, however pure,
No virtue can be long secure:
Shun then the traitress and her wiles,
Whate’er she touches she defiles.

Reflection.

It is of no small importance in life, to be cautious what company

we keep, and with whom we enter into friendships. For though we
are ever so well disposed ourselves, and happen to be ever so free
from vice and debauchery, yet, if those with whom we frequently
converse are engaged in a lewd, wicked course, it will be almost
impossible for us to escape being drawn in with them.
If we are truly wise, and would shun those siren rocks of pleasure
upon which so many have split before us, we should forbid ourselves
all manner of commerce and correspondence with those who are
steering a course which, reason tells us, is not only not for our
advantage, but must end in our destruction.
All the virtue we can boast of will not be sufficient to ensure us, if
we embark in bad company. For though our philosophy were such,
as that we could preserve ourselves from being tainted and infected
with their manners, yet their character would twist and entwine itself
along with ours in so intricate a fold, that the world would not take
the trouble to unravel and separate them. Reputations are of a
subtle insinuating texture like water; that which is derived from the
clearest spring, if it chances to mix with a foul current, runs on,
undistinguished, in one muddy stream for the future, and must for
ever partake of the colour and condition of its associate.
 Fable LXV.
The Boy and his Mother.
A little Boy, who went to school, stole one of his school-fellow’s
horn-books, and brought it home to his mother; who was so far
from correcting and discouraging him upon account of the theft, that
she commended and gave him an apple for his pains. In process of
time, as the child grew up to be a man, he accustomed himself to
greater robberies; and at last, being apprehended and committed to
gaol, he was tried and condemned for a felony. On the day of his
execution, as the officers were conducting him to the gallows, he
was attended by a vast crowd of people, and among the rest by his
mother, who came sighing and sobbing along, and deploring
extremely her son’s unhappy fate; which the criminal observing, he
called to the sheriff, and begged the favour of him, that he would
give him leave to speak a word or two to his poor afflicted mother.
The sheriff (as who would deny a dying man so reasonable a
request) gave him permission; and the felon, while every one
thought he was whispering something of importance to his mother,
bit off her ear, to the great offence and surprise of the whole
assembly. What, say they, was not this villain contented with the
impious acts which he has already committed, but he must increase
the number of them, by doing this violence to his mother? Good
people, replied he, I would not have you be under a mistake; that
wicked woman deserves this, and even worse at my hands; for if she
had chastised and chid, instead of rewarding and caressing me,
when in my infancy I stole the horn-book from the school, I had not
come to this ignominious untimely end.

Morals.

Youthful minds, like the pliant wax, are susceptible

of the most lasting impressions, and the good or evil
bias they then receive is seldom or ever eradicated.

Fathers and mothers! train your children’s youth

To virtue, honour, honesty, and truth;
Dreadful! to bring about your child’s damnation,
And give your sons a Tyburn education.

Reflection.

Notwithstanding the great innate depravity of mankind, one need

not scruple to affirm, that most of the wickedness, which is so
frequent and so pernicious in the world, arises from a bad
education; and that the child is obliged either to the example or
connivance of its parents, for most of the vicious habits which it
wears through the course of its future life. The mind of one that is
young is, like wax, soft and capable of any impression which is given
it: but it is hardened by time, and the first signature grows so firm
and durable, that scarce any pains or application can erase it. It is a
mistaken notion in people, when they imagine that there is no
occasion for regulating or restraining the actions of very young
children, which though allowed to be sometimes very naughty in
those of a more advanced age, are in them, they suppose,
altogether innocent and inoffensive. But, however innocent they may
be, as to their intention then, yet, as the practice may grow upon
them unobserved, and root itself into a habit, they ought to be
checked and discountenanced in their first efforts towards anything
that is injurious or dishonest; that the love of virtue and the
abhorrence of wrong and oppression may be let into their minds, at
the same time that they receive the very first dawn of
understanding, and glimmering of reason. Whatever guilt arises from
the actions of one whose education has been deficient as to this
point, no question but a just share of it will be laid, by the great
Judge of the world, to the charge of those who were, or should have
been, his instructors.

Fable LXVI.
The Wanton Calf.
 A Calf, full of play and wantonness, seeing the Ox at plough, could
not forbear insulting him. What a sorry poor drudge art thou, says
he, to bear that heavy yoke upon your neck, and go all day drawing
a plough at your tail, to turn up the ground for your master! But you
are a wretched dull slave, and know no better, or else you would not
do it. See what a happy life I lead; I go just where I please;
sometimes I lie down under the cool shade; sometimes frisk about in
the open sunshine; and, when I please, slake my thirst in the clear
sweet brook: But you, if you were to perish, have not so much as a
little dirty water to refresh you. The Ox, not at all moved with what
he said, went quietly and calmly on with his work: and, in the
evening, was unyoked and turned loose. Soon after which he saw
the Calf taken out of the field, and delivered into the hands of a
priest, who immediately led him to the altar, and prepared to
sacrifice him. His head was hung round with fillets of flowers, and
the fatal knife was just going to be applied to his throat, when the
Ox drew near and whispered him to this purpose: Behold the end of
your insolence and arrogance; it was for this only you were suffered
to live at all; and pray now, friend, whose condition is best, yours or
mine?

Morals.

To insult people in distress is the property of a cruel,

indiscreet, and giddy temper; for on the next turn of
fortune’s wheel, we may be thrown down to their
condition, and they exalted to ours.

Thus oft the industrious poor endures reproach

From rogues in lace, and sharpers in a coach;
But soon to Tyburn sees the villains led,
While he still earns in peace his daily bread.
 Reflection.

We may learn by this Fable the consequence of an idle life, and

how well satisfied laborious, diligent men are, in the end, when they
come quietly to enjoy the fruits of their industry. They who, by little
tricks and sharpings, or by open violence and robbery, live in a high
extensive way, often, in their hearts at least, despise the poor
honest man, who is contented with the virtuous product of his daily
labour, and patiently submits to his destiny. But how often is the
poor man comforted, by seeing these wanton villains led in triumph
to the altar of justice, while he has many a cheerful summer’s
morning to enjoy abroad, and many a long winter’s evening to
indulge himself in at home, by a quiet hearth, and under an
unenvied roof: Blessings, which often attend a sober, industrious
man, though the idle and the profligate are utter strangers to them.
Luxury and intemperance, besides their being certain to shorten a
man’s days, are very apt not only to engage people with their
seeming charms into a debauched life, utterly prejudicial to their
health, but to make them have a contempt for others, whose good
sense and true taste of happiness inspire them with an aversion to
idleness and effeminacy, and put them upon hardening their
constitution by innocent exercise and laudable employment. How
many do gluttony and sloth tumble into an untimely grave! while the
temperate and the active drink sober draughts of life, and spin out
their thread to the most desirable length.
 Fable LXVII.
Jupiter and the Herdsman.
A Herdsman, missing a young heifer that belonged to his herd,
went up and down the forest to seek it. And having walked a great
deal of ground to no purpose, he fell a praying to Jupiter for relief;
promising to sacrifice a Kid to him, if he would help him to a
discovery of the thief. After this, he went on a little farther, and came
near a grove of oaks, where he found the carcase of his heifer, and a
lion grumbling over it, and feeding upon it. This sight almost scared
him out of his wits; so down he fell upon his knees once more, and
addressing himself to Jupiter; O Jupiter! says he, I promised thee a
Kid to show me the thief, but now I promise thee a bull, if thou wilt
be so merciful as to deliver me out of his clutches.

Morals.
 We ought never to supplicate the Divine power, but
through motives of religion and virtue; prayers,
dictated by passion or interest, are unacceptable to the
Deity.

Short-sighted wretch! endure thy care,

Nor heave th’ impatient sigh:
Heav’n hears thee, but perhaps thy pray’r
’Tis mercy to deny.

Reflection.

How ignorant and stupid are some people, who form their notions
of the Supreme Being from their own poor shallow conceptions; and
then, like froward children with their nurses, think it consistent with
infinite wisdom and unerring justice to comply with all their
whimsical petitions. Let men but live as justly as they can, and just
Providence will give them what they ought to have. Of all the
involuntary sins which men commit, scarce any are more frequent,
than that of their praying absurdly and improperly, as well as
unseasonably, when their time might have been employed so much
better. The many private collections, sold up and down the nation,
do not a little contribute to this injudicious practice: Which is the
more to be condemned, in that we have so incomparable a public
liturgy; one single address whereof (except the Lord’s Prayer) may
be pronounced to be the best that ever was compiled; and alone
preferable to all the various manuals of occasional devotion, which
are vended by hawkers and pedlars about our streets. It is as
follows:—

Almighty God, the fountain of all wisdom, who

knowest our necessities before we ask, and our
ignorance in asking; we beseech thee to have
 compassion upon our infirmities; and those things,
which for our unworthiness we dare not, and for our
blindness we cannot ask, vouchsafe to give us, for the
worthiness of thy Son Jesus Christ our Lord.

Fable LXVIII.
There’s no To-morrow.
A Man, who had lived a very profligate life, at length being
awakened by the lively representations of a sober friend on the
apprehensions of a feverish indisposition, promised that he would
heartily set about his reformation, and that To-morrow he would
seriously begin it. But the symptoms going off, and that To-morrow
coming, he still put it off till the next, and so he went on from one
To-morrow to another; but still he continued his reprobate life. This
his friend observing, said to him, I am very much concerned to find
how little effect my disinterested advice has upon you: But, my
friend, let me tell you, that since your To-morrow never comes, nor
do you seem to intend it shall, I will believe you no more, except you
set about your repentance and amendment this very moment: for, to
say nothing of your repeated broken promises, you must consider,
that the time that is past is no more; that To-morrow is not OURS;
and the present NOW is all we have to boast of.

Morals.

That compunction of heart cannot be sincere, which

takes not immediate effect, and can be put off till To-
morrow. The friend’s closing observation in the Fable is
so good a moral, that we need add nothing to it.

Eager to mend, and brookless of delay,

Sincere repentance waits no future day;
The present moment only is allow’d;
Uncertain hopes and fears to-morrow shroud.

Reflection.

Whoever considers this emblem, will find it to be his own case; we

promise, and we put off, and we sin, and go on sinning: but still, as
our conscience checks us for it, we take up faint purposes, and half
resolutions, to do so no more, and to lead a new life for the future.
Thus, with the young fellow here, we indulge ourselves in our
pleasures from time to time; and when we have trifled away our
lives, day after day, from one To-morrow to another, that same To-
morrow never comes. This is the sluggard’s plea and practice; the
libertine’s, the miser’s; and in short, whose is it not? Now, if we
would but consider the vanity and vexation of a lewd course of life;
the impiety first of entering into vows, which we intend beforehand
not to perform, and afterward of breaking them; the folly and the
presumption of undertaking anything that is wholly out of our
power; the necessity of improving every moment of our lives; the
desperate and the irreparable hazard of losing opportunities; we
should not venture body and soul upon the necessity of a
procrastinated repentance, and postpone the most certain duties of
a man, and of a Christian; for there is no To-morrow, nor anything,
in truth, but the present instant, that we can call our own.
 Part III.
FABLES, in Verse.

Fable I.
The Cuckoo Traveller.
A Cuckoo once, as Cuckoos use,
Who’d been upon a winter’s cruise,
Return’d with the returning spring—
Some hundred brothers of the wing,
Curious to hear from foreign realms,
Got round him in a tuft of elms.
He shook his pinions, struck his beak,
Attempted twice or thrice to speak;
At length, up-rising on his stand,

“Old England! Well, the land’s a land!

But rat me, gentlemen,” says he,
“We passage-fowl that cross the sea
Have vast advantages o’er you;
Whose native woods are all you view.
The season past, I took a jaunt
Among the isles of the Levant;
Where, by the way, I stuff’d my guts
With almonds and pistachio nuts.
’Twas then my whim some weeks to be
In that choice garden, Italy:
But, underneath the sky’s expanse,
No climate like the south of France!
You’ve often heard, I dare to swear,
How plenty ortolans are there;
’Tis true, and more delicious meat,
Upon my honour, I ne’er eat;
The eggs are good; it was ill luck
What day I had not ten to suck;
Yet notwithstanding, to my goût,
The bird’s the sweeter of the two.”
He went on, talking pert and loud,
When an old Raven, ’mongst the crowd,
Stopp’d short his insolent career—
“Why, what a monstrous bustle’s here!
Y t ll’d i ! I kt
You travell’d, sir! I speak to you,
Who’ve passed so many countries thro’;
Say, to what purpose is’t you roam,
And what improvements bring you home?
Has Italy, on which you doat,
Supply’d you with another note?
Or France, which you extol so high,
Taught you with better grace to fly?
I cannot see that both together
Have alter’d you a single feather:
Then tell not us of where you’ve been,
Of what you’ve done, or what you’ve seen;
While you and all your rambling pack
Cuckoos go out, Cuckoos come back.”

Fable II.
The Ant and the Grasshopper.
’Twas that bleak season of the year,
In which no smiles, no charms appear;
Bare were the trees; the rivers froze;
The hills and mountains capt with snows;
When, lodging scarce and victuals scant,
A Grasshopper address’d an Ant:
And, in a supplicating tone,
Begg’d he would make her case his own.

“It was, indeed, a bitter task

To those who were unused to ask;
Yet she was forc’d the truth to say,
She had not broke her fast that day;
His worship, tho’, with plenty bless’d,
Knew how to pity the distress’d;
A grain of corn to her was gold,
And Heav’n would yield him fifty-fold.”

The Ant beheld her wretched plight,

Nor seem’d unfeeling at the sight;
Yet, still inquisitive to know
How she became reduc’d so low,
Asked her—we’ll e’en suppose in rhyme—
What she did all the summer time?

“In summer time, good sir,” said she,

“Ah! these were merry months with me!
I thought of nothing but delight,
And sung, Lord, help me! day and night:
Through yonder meadows did you pass,
You must have heard me in the grass.”

“Ah!” cry’d the Ant, and knit his brow—

“But ’tis enough I hear you now;
And, Madam Songstress, to be plain,
You seek my charity in vain:
 ou see y c a ty a
What, shall th’ industrious yield his due
To thriftless vagabonds like you!
Some corn I have, but none to spare,
Next summer learn to take more care;
And in your frolic moods, remember,
July is follow’d by December.”

Fable III.
The Wolf and the Dog.
A prowling Wolf, that scour’d the plains,
To ease his hunger’s griping pains,
Ragged as courtier in disgrace,
Hide-bound, and lean, and out of case,
By chance a well-fed Dog espy’d,
And being kin, and near ally’d,
He civilly salutes the cur:
“How do you, Cuz? Your servant, sir.
O happy friend! how gay thy mien!
How plump thy sides, how sleek thy skin!
Triumphant plenty shines all o’er,
And the fat melts at ev’ry pore!
While I, alas! decay’d and old,
With hunger pin’d, and stiff with cold,
With many a howl and hideous groan,
Tell the relentless woods my moan.
Pr’ythee (my happy friend!) impart
Thy wondrous, cunning, thriving art.”
“Why, faith, I’ll tell thee as a friend,
But first thy surly manners mend;
Be complaisant, obliging, kind,
And leave the Wolf for once behind.”
The Wolf, whose mouth began to water,
With joy and rapture gallop’d after,
When thus the Dog: “At bed and board,
I share the plenty of my lord;
From ev’ry guest I claim a fee,
Who court my lord by bribing me.
In mirth I revel all the day,
And many a game at romps I play:
I fetch and carry, leap o’er sticks,
With twenty such diverting tricks.”
“’Tis pretty, faith,” the Wolf reply’d,
And on his neck the collar spy’d:
He starts, and without more ado,
He bids the abject wretch adieu:
“Enjoy your dainties, friend; to me
The noblest feast is liberty:
The famish’d Wolf, upon these desert plains,
Is happier than a fawning cur in chains.”

Fable IV.
The Nightingale.
How few with patience can endure
The evils they themselves procure.
A Nightingale, with snares beset,
At last was taken in a net:
When first she found her wings confin’d,
She beat and flutter’d in the wind,
Still thinking she could fly away;
Still hoping to regain the spray:
But, finding there was no retreat,
Her little heart with anger beat;
Nor did it aught abate her rage;
To be transmitted to a cage.
The wire apartment, tho’ commodious,
To her appear’d excessive odious;
And though it furnish’d drink and meat,
She car’d not, for she could not eat;
’Twas not supplying her with food;
She lik’d to gather it from the wood:
And water clear, her thirst to slake,
She chose to sip from the cool lake:
And, when she sung herself to rest,
’Twas in what hedge she lik’d the best:
And thus, because she was not free,
Hating the chain of slavery,
She rather added link to link:
—Just so men reach misfortune’s brink.
At length, revolving on her state,
She cries, “I might have met worse fate,
Been seiz’d by kites or prowling cat,
Or stifled in a school boy’s hat;
Or been the first unlucky mark,
Sure hit by some fantastic spark.”
Then conscience told her, want of care
Had made her fall into the snare;
That men were free their nets to throw;
And birds were free to come or go:
And all the evils she lamented,
By caution might have been prevented.
So, on her perch more pleas’d she stood,
And peck’d the kindly offer’d food;
Resolv’d, with patience, to endure
Ills she had brought, but could not cure.

Fable V.
The Two Foxes.
Two hungry Foxes once agreed
To execute a bloody deed,
And make the farmer’s poultry bleed.
Thus, as their rage was very hot,
Cocks, hens, and chickens went to pot.
The one (the slaughter being o’er)
Young, and a perfect epicure,
Propos’d on all the spoil to sup,
And at one meal to eat it up.
The other old, at heart a miser,
Refus’d his scheme, and thought it wiser
To lay aside some of the prey,
And so provide for a bad day.
“Listen, my child,” says he, “to age;
Experience has made me sage:
I know the various turns of fate:
How changeable is every state!
A mighty treasure we have found;
Success has all our wishes crown’d;
See! the vast havoc all around!
Oh let us not be lavish, son,
Nor throw away what we have won!
Oh let us not consume our store,
But, being frugal, make it more!”
“Your fine harangue,” replies the other,
“Might take, were I a griping brother:
But, as I’m generous and free,
It ne’er shall have effect on me.
I’ll live, old daddy, while I may
Indulge my noble self with prey,
And feast in spite of all you say.
But should I not—why, to our sorrow,
The fowls will stink before to-morrow.
If we return—the clown will watch us;
And, hang the dog, he’ll surely catch us:
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