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Suggested doses for antibiotics recommended in the treatment of suspected staphylococcal or streptococcal skin and soft tissue infections in neonates

Suggested doses for antibiotics recommended in the treatment of suspected staphylococcal or streptococcal skin and soft tissue infections in neonates
Parenteral antibiotics for initiation of therapy
Antibiotic agent Dosing
GA <32 weeks GA ≥32 weeks
Cefazolin
  • Age <7 days: 25 mg/kg IV every 12 hours
  • Age ≥7 days: 25 mg/kg IV every 8 hours
  • Age ≤7 days: 50 mg/kg IV every 12 hours
  • Age >7 days: 50 mg/kg IV every 8 hours
Cefotaxime
  • Age <7 days: 50 mg/kg IV every 12 hours
    Age ≥7 days: 50 mg/kg IV every 8 hours
Ceftazidime
Ceftriaxone*
  • 50 mg/kg IV every 24 hours
Clindamycin
  • PMA ≤32 weeks: 5 mg/kg IV every 8 hours
  • PMA 33 to 40 weeks: 7 mg/kg IV every 8 hours
  • PMA >40 weeks: 9 mg/kg IV every 8 hours
Antibiotic agent Dosing
GA <36 weeks GA ≥36 weeks
Cefepime
  • 30 mg/kg IV every 12 hours
  • 50 mg/kg IV every 12 hours
Antibiotic agent Dosing
GA ≥34 weeks and age ≥12 days
Ceftaroline
  • 6 mg/kg IV every 8 hours
Antibiotic agent Dosing
GA <30 weeks GA 30 to 34 weeks GA ≥35 weeks
GentamicinΔ
  • Age ≤14 days: 5 mg/kg IV every 48 hours
  • Age >14 days: 5 mg/kg IV every 36 hours
  • Age ≤10 days: 5 mg/kg IV every 36 hours
  • Age >10 days: 5 mg/kg IV every 24 hours
  • Age ≤7 days: 4 mg/kg IV every 24 hours
  • Age >7 days: 5 mg/kg IV every 24 hours
Antibiotic agent Dosing
Age ≤7 days Age 8 to 28 days
Linezolid
  • GA <34 weeks: 10 mg/kg IV every 12 hours
  • GA ≥34 weeks: 10 mg/kg IV every 8 hours
  • 10 mg/kg IV every 8 hours
Nafcillin
  • GA ≤34 weeks: 25 mg/kg IV every 12 hours
  • GA >34 weeks: 25 mg/kg IV every 8 hours
  • GA ≤34 weeks: 25 mg/kg IV every 8 hours
  • GA >34 weeks: 25 mg/kg IV every 6 hours
Oxacillin
  • GA ≤34 weeks: 25 mg/kg IV every 12 hours
  • GA >34 weeks: 25 mg/kg IV every 8 hours
  • GA ≤34 weeks: 25 mg/kg IV every 8 hours
  • GA >34 weeks: 25 mg/kg IV every 6 hours
Piperacillin-tazobactam
  • PMA ≤30 weeks: 100 mg/kg IV every 8 hours
  • PMA >30 weeks: 80 mg/kg IV every 6 hours
Vancomycin§ Begin with a loading dose of 20 mg/kg followed by maintenance dosing according to GA and serum creatinine as indicated below. The interval between the loading dose and the first maintenance dose should be the same as the dosing interval for the maintenance regimen. This dosing regimen was designed with a target trough concentration of 5 to 10 mg/L[1].
GA ≤28 weeks GA >28 weeks
Serum creatinine Dose and frequency Serum creatinine Dose and frequency
  • <0.5
  • 15 mg/kg IV every 12 hours
  • <0.7
  • 15 mg/kg IV every 12 hours
  • 0.5 to 0.7
  • 20 mg/kg IV every 24 hours
  • 0.7 to 0.9
  • 20 mg/kg IV every 24 hours
  • 0.8 to 1
  • 15 mg/kg IV every 24 hours
  • 1 to 1.2
  • 15 mg/kg IV every 24 hours
  • 1.1 to 1.4
  • 10 mg/kg IV every 24 hours
  • 1.3 to 1.6
  • 10 mg/kg IV every 24 hours
  • >1.4
  • 15 mg/kg IV every 48 hours
  • >1.6
  • 15 mg/kg IV every 48 hours
Oral antibiotics for completion of therapy¥
Antibiotic agent Dosing
Age ≤7 days Age 8 to 28 days
Cephalexin
  • Oral therapy not appropriate
  • 6.25 to 12.5 mg/kg orally every 6 hours
Clindamycin
  • PMA ≤32 weeks: 5 mg/kg orally every 8 hours
  • PMA 33 to 40 weeks: 7 mg/kg orally every 8 hours
  • PMA >40 weeks: 9 mg/kg orally every 8 hours
Linezolid
  • GA <34 weeks: 10 mg/kg orally every 12 hours
  • GA ≥34 weeks: 10 mg/kg orally every 8 hours
  • 10 mg/kg orally every 8 hours
This table provides the doses of antibiotics that may be used in the treatment of staphylococcal or streptococcal SSTIs in neonates. Refer to UpToDate content on SSTIs in neonates for details regarding the choice of antimicrobial therapy. Unless otherwise specified, "age" refers to postnatal age.
GA: gestational age; IV: intravenously; PMA: postmenstrual age; SSTI: skin and soft tissue infection; MRSA: methicillin-resistant Staphylococcus aureus; MSSA: methicillin-susceptible S. aureus; AUC: area under the curve; PNA: postnatal age.
* Ceftriaxone should not be administered to neonates if they are also receiving intravenous calcium in any form.
¶ Monitor carefully when used if more than 15% of local community-associated S. aureus isolates are resistant to clindamycin.
Δ Gentamicin is necessary to provide coverage for possible gram-negative pathogens. The optimal, individualized dose should be based on determination of serum concentrations. Doses may differ from those recommended by the package insert.
If there is another indication for piperacillin-tazobactam (eg, Pseudomonas infection).
§ Serum creatinine concentration will take approximately 5 to 7 days after birth to reasonably reflect neonatal renal function. Cautious use of creatinine-based dosing strategy with frequent assessment of renal function and vancomycin serum concentrations are recommended in neonates ≤7 days old[2]. A vancomycin dosing method based upon PMA and PNA is provided as an alternative to the serum creatinine-based method listed above and may be useful in some clinical situations[3]. The regimen was designed with a target trough concentration of 10 to 20 mg/L.
  • PMA ≤29 weeks
    • PNA ≤21 days: 15 mg/kg IV every 18 hours
    • PNA >21 days: 15 mg/kg IV every 12 hours
  • PMA 30 to <37 weeks
    • PNA ≤14 days: 15 mg/kg IV every 12 hours
    • PNA >14 days: 15 mg/kg IV every 8 hours
  • PMA 37 to <45 weeks
    • PNA ≤7 days: 15 mg/kg IV every 12 hours
    • PNA >7 days: 15 mg/kg IV every 8 hours
The approach to vancomycin dosing (trough-guided or AUC-guided) is generally determined at the institutional level. Refer to UpToDate content on invasive staphylococcal infections in children for details of trough-guided or AUC-guided vancomycin dosing.
¥ Oral therapy should be directed by results of antibiotic susceptibility testing. If no pathogen is identified, we provide coverage for both MRSA and MSSA (eg, clindamycin).
‡ Oral linezolid is reserved for isolates resistant to other agents; consultation with an expert in infectious diseases is suggested to ensure that it is the only oral option.
References:
  1. Capparelli EV, Lane JR, Romanowski GL, et al. The influences of renal function and maturation on vancomycin elimination in newborns and infants. J Clin Pharmacol, 2001; 41:927.
  2. Nelson's Pediatric Antimicrobial Therapy, 27th ed, Bradley JS, Nelson JD, Barnett ED, et al (Eds), American Academy of Pediatrics, Itasca, IL 2021. p.100.
  3. Radu L, Bengry T, Akierman A, et al. Evolution of empiric vancomycin dosing in a neonatal population. J Perinatol. 2018; 38:1702.
Data adapted from: American Academy of Pediatrics. Tables of antibacterial drug dosages. In: Red Book: 2021-2024 Report of the Committee on Infectious Diseases, 32nd ed, Kimberlin DW, Barnett ED, Lynfield R, Sawyer MH (Eds), American Academy of Pediatrics, Itasca, IL 2021. p.876.
Additional data from: Teflaro (ceftaroline fosamil) for injection. United States Prescribing Information. Revised September 2019. US Food & Drug Administration. Available at: https://www.accessdata.fda.gov/scripts/cder/daf/ (Accessed on October 22, 2019).
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