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Suggested antimicrobial regimens in the management of neonatal sepsis in term and late preterm infants

Suggested antimicrobial regimens in the management of neonatal sepsis in term and late preterm infants
  Antibiotic regimen
Empiric therapy
Early onset (<7 days) Ampicillin and gentamicin
Late onset (≥7 days) – Admitted from the community

Preferred regimen – Ampicillin and gentamicin

Alternative – Ampicillin and an expanded-spectrum cephalosporin (eg, ceftazidime, cefepime, or cefotaxime [where available])
Late onset (≥7 days) – Hospitalized since birth Gentamicin and vancomycin
Special circumstances:
Suspected meningitis – Early onset Ampicillin and gentamicin*
Suspected meningitis – Late onset, admitted from the community Ampicillin, gentamicin, and an expanded-spectrum cephalosporin (eg, ceftazidime, cefepime, or cefotaxime [where available])
Suspected meningitis – Late onset, hospitalized since birth Gentamicin, vancomycin, and an expanded-spectrum cephalosporin (eg, ceftazidime, cefepime, or cefotaxime [where available])
Suspected pneumonia

Ampicillin and gentamicin

Alternatives:
  • Ampicillin and expanded-spectrum cephalosporin, or
  • Vancomycin and expanded-spectrum cephalosporin, or
  • Vancomycin and gentamicin
Suspected infection of soft tissues, skin, joints, or bones (S. aureus is a likely pathogen)

Vancomycin and gentamicin, or

Vancomycin, nafcillin, and gentamicin, or

Vancomycin and an expanded-spectrum cephalosporin (eg, ceftazidime, cefepime, or cefotaxime [where available])
Suspected intravascular catheter-related infection Vancomycin and gentamicin
Suspected infection due to organisms found in the gastrointestinal tract (eg, anaerobic bacteria)

Ampicillin, gentamicin, and clindamycin

Alternatives:
  • Ampicillin, gentamicin, and metronidazole or
  • Piperacillin-tazobactam and gentamicin
Pathogen-specific therapy
Group B Streptococcus Penicillin G
E. coli – Ampicillin-sensitive Ampicillin
E. coli – Ampicillin-resistant

Expanded-spectrum cephalosporin (eg, ceftazidime, cefepime, or cefotaxime [where available])

Alternative:
  • Meropenem
Multidrug-resistant gram-negative bacilli (including ESBL-producing organisms) Meropenem
L. monocytogenes Ampicillin and gentamicin
MSSA Nafcillin or cefazolin
MRSA Vancomycin
Coagulase-negative staphylococci Vancomycin
S. aureus: Staphylococcus aureus; E. coli: Escherichia coli; ESBL: extended-spectrum beta-lactamase; L. monocytogenes: Listeria monocytogenes; MSSA: methicillin-susceptible S. aureus; MRSA: methicillin-resistant S. aureus.
* An expanded-spectrum cephalosporin (eg, cefotaxime [where available], ceftazidime, or cefepime) should be added to the empiric regimen for suspected early-onset meningitis if the cerebrospinal fluid Gram stain reveals gram-negative bacilli.
¶ If there is concern for meningitis caused by a multidrug-resistant gram-negative organism, a carbapenem such as meropenem is the preferred agent for empiric therapy.
References:
  1. Edwards MS, Baker CJ. Bacterial infections in the neonate. In: Principles and Practice of Pediatric Infectious Diseases, 5th ed, Long SS, Prober CG, Fischer M (Eds), Elsevier 2018. p.549.
  2. Nizet V, Klein JO. Bacterial sepsis and meningitis. In: Infectious Diseases of the Fetus and Newborn Infant, 8th ed, Wilson CB, Nizet V, Maldonado YA, et al (Eds), Elsevier Saunders 2016. p.217.
  3. American Academy of Pediatrics. Group B streptococcal infections. In: Red Book: 2018-2021 Report of the Committee on Infectious Diseases, 31st ed, Kimberlin DW (Ed), American Academy of Pediatrics 2018. p.762.
  4. American Academy of Pediatrics. Serious bacterial infections caused by Enterobacteriaceae (with emphasis on septicemia and meningitis in neonates). In: Red Book: 2018-2021 Report of the Committee on Infectious Diseases, 31st ed, Kimberlin DW (Ed), American Academy of Pediatrics 2018. p.328.
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