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

	Antibiotic regimen
Empiric therapy
Early onset (<72 hours)	Ampicillin and an aminoglycoside (typically gentamicin)*
Late onset (≥72 hours) – Admitted from the community	Preferred regimen – Ampicillin and an aminoglycoside (typically gentamicin)* Alternative – Ampicillin and an expanded-spectrum cephalosporin (eg, ceftazidime, cefepime, or cefotaxime [where available])
Late onset (≥72 hours) – Hospitalized since birth	Vancomycin or nafcillin/oxacillin^¶, and An aminoglycoside (typically gentamicin)*
Special circumstances:
Suspected meningitis (eg, CSF pleocytosis)	Same as above except substitute an expanded-spectrum cephalosporin (eg, ceftazidime, cefepime, or cefotaxime [where available]) for the aminoglycoside^Δ
Suspected pneumonia	Ampicillin and an aminoglycoside (typically gentamicin)* Alternatives: Ampicillin and expanded-spectrum cephalosporin, or Vancomycin and expanded-spectrum cephalosporin, or Vancomycin and an aminoglycoside (typically gentamicin)*
Suspected infection of skin, umbilicus, soft tissues, joints, or bones (S. aureus is a likely pathogen)	Vancomycin and an aminoglycoside (typically gentamicin), or Vancomycin, nafcillin, and* an aminoglycoside (typically gentamicin), or Vancomycin and* an expanded-spectrum cephalosporin (eg, ceftazidime, cefepime, or cefotaxime [where available])
Suspected intravascular catheter-related infection	Vancomycin and an aminoglycoside (typically gentamicin)*
Suspected infection due to organisms found in the gastrointestinal tract (eg, anaerobic bacteria)	Ampicillin, an aminoglycoside (typically gentamicin), and* clindamycin Alternatives: Ampicillin, an aminoglycoside (typically gentamicin), and* metronidazole or Piperacillin-tazobactam and an aminoglycoside (typically 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	Oxacillin/nafcillin or cefazolin
MRSA	Vancomycin
Coagulase-negative staphylococci	Vancomycin

This table summarizes our suggested antibiotic regimens for empiric and pathogen-specific therapy for neonatal sepsis. The initial choice of empiric therapy depends on the neonate's age, likely pathogens, and presence of an apparent source of infection (eg, skin, joint, or bone involvement). Local antibiotic susceptibility patterns should also be considered.

CSF: cerebrospinal fluid; E. coli: Escherichia coli; ESBL: extended-spectrum beta-lactamase; L. monocytogenes: Listeria monocytogenes; MSSA: methicillin-susceptible Staphylococcus aureus; MRSA: methicillin-resistant Staphylococcus aureus.

* In centers with a high prevalence of gentamicin resistance among gram-negative isolates, an alternative aminoglycoside (eg, amikacin) may be preferred. Refer to UpToDate's topics on neonatal sepsis for additional details.

¶ Nafcillin or oxacillin can be used in the empiric regimen in lieu of vancomycin if the neonate is not critically ill and has a recent negative MRSA screening test.

Δ 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.

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