Suggested parenteral antibiotic regimens for mastitis or breast abscess in infants without severe complications,* according to most frequent gram stain findings

Parenteral antibiotics	Infants ≤28 days	Infants >28 days
Gram-positive cocci
CA-MRSA not a concern (one of the following)
Nafcillin or oxacillin	GA ≤34 weeks: Age ≤7 days: 25 mg/kg IV every 12 hours Age >7 days: 25 mg/kg IV every 8 hours GA >34 weeks: Age ≤7 days: 25 mg/kg IV every 8 hours Age >7 days: 25 mg/kg IV every 6 hours	100 to 200 mg/kg IV per day in 4 to 6 doses
CA-MRSA a concern (one of the following)
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	20 to 40 mg/kg IV per day in 3 or 4 doses
Vancomycin^Δ	Loading dose: 20 mg/kg IV 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: <0.5 mg/dL: 15 mg/kg IV every 12 hours 0.5 to 0.7 mg/dL: 20 mg/kg IV every 24 hours 0.8 to 1 mg/dL: 15 mg/kg IV every 24 hours 1.1. to 1.4 mg/dL: 10 mg/kg IV every 24 hours >1.4 mg/dL: 15 mg/kg IV every 48 hours GA >28 weeks: <0.7 mg/dL: 15 mg/kg IV every 12 hours 0.7 to 0.9 mg/dL: 20 mg/kg IV every 24 hours 1 to 1.2 mg/dL: 15 mg/kg IV every 24 hours 1.3 to 1.6 mg/dL: 10 mg/kg IV every 24 hours >1.6 mg/dL: 15 mg/kg IV every 48 hours	Refer to UpToDate content related to alternative methods of dosing vancomycin for children older than 28 days^◊
Gram-negative organisms (one of the following)
Gentamicin^§	GA <30 weeks: Age ≤14 days: 5 mg/kg IV every 48 hours Age >14 days: 5 mg/kg IV every 36 hours GA 30 to 34 weeks: Age ≤10 days: 5 mg/kg IV every 36 hours Age >10 days: 5 mg/kg IV every 24 hours GA ≥35 weeks: Age ≤7 days: 4 mg/kg IV every 24 hours Age >7 days: 5 mg/kg IV every 24 hours	6 to 7.5 mg/kg IV per day in 3 doses, or 5 to 7.5 mg/kg IV per day once daily
Amikacin^§	GA <30 weeks: Age ≤14 days: 15 mg/kg IV every 48 hours Age >14 days: 15 mg/kg IV every 24 hours GA 30 to 34 weeks: Age ≤10 days: 15 mg/kg IV every 36 hours Age >10 days: 15 mg/kg IV every 24 hours GA ≥35 weeks: Age ≤7 days: 15 mg/kg IV every 24 hours Age >7 days: 18 mg/kg IV every 24 hours	15 to 22.5 mg/kg IV per day in 2 or 3 doses or once daily
Cefotaxime^¥ (if available)	Age <7 days: 50 mg/kg IV every 12 hours Age ≥7 days: 50 mg/kg IV every 8 hours	150 to 180 mg/kg IV per day in 3 doses 200 to 225 mg/kg IV per day in 4 doses for meningitis
Ceftazidime^¥ (if cefotaxime not available)	Age <7 days: 50 mg/kg IV every 12 hours Age ≥7 days: 50 mg/kg IV every 8 hours	90 to 150 mg/kg IV per day in 3 doses 200 to 300 mg/kg IV per day in 3 doses for suspected Pseudomonas (severe infection)
Ceftriaxone^¥^‡ (if cefotaxime not available)	50 mg/kg IV every 24 hours	50 to 75 mg/kg IV per day 100 mg/kg IV per day in 1 or 2 doses for meningitis
Gram stain not available or no organisms seen
CA-MRSA not a concern
Nafcillin or oxacillin, plus one of the following: Gentamicin^§ Amikacin^§ Cefotaxime^¥ Ceftazidime^¥ Ceftriaxone^¥	Dosing regimens provided above
CA-MRSA a concern
Clindamycin^¶ or vancomycin, plus one of the following: Gentamicin^§ Amikacin^§ Cefotaxime^¥ Ceftazidime^¥ Ceftriaxone^¥	Dosing regimens provided above

Refer to UpToDate content on mastitis and breast abscess in infants for additional information. The doses in this table are intended for patients with normal renal function. The doses of many of these agents must be adjusted in the setting of renal insufficiency; refer to the Lexicomp drug-specific monographs for renal dose adjustments. Unless otherwise specified, "age" refers to postnatal age.

CA-MRSA: community-acquired methicillin-resistant Staphylococcus aureus; GA: gestational age; IV: intravenously; PMA: postmenstrual age; PNA: postnatal age; AUC: area under the curve.
* Severe complications include extensive cellulitis, necrotizing fasciitis, osteomyelitis, and shock. Refer to UpToDate content on mastitis and shock in infants.
¶ Clindamycin should not be used if central nervous system infection is a concern. Monitor carefully when used if more than 15% of local community-associated S. aureus isolates are resistant to clindamycin.
Δ 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 is generally determined at the institutional level. Refer to UpToDate content on invasive staphylococcal infections in children for details of trough-guided and AUC-guided vancomycin dosing for infants ≥28 days of age.
§ Initial aminoglycoside dosing is provided. The optimal, individualized dose of amikacin and gentamicin should be based on determination of serum concentrations. Doses may differ from those recommended by the package insert.
¥ Cefotaxime (if available), ceftazidime, or ceftriaxone is recommended if cerebrospinal fluid is abnormal.
‡ Intravenous ceftriaxone should be avoided in infants who are also receiving or are expected to receive intravenous calcium in any form, including parenteral nutrition.

References:

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.
Nelson's Pediatric Antimicrobial Therapy, 27^rd ed, Bradley JS, Nelson JD, Barnett ED, et al (Eds), American Academy of Pediatrics, Itasca, IL 2021. p.100.
Radu L, Bengry T, Akierman A, et al. Evoluation 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, 32^nd ed, Kimberlin DW, Barnett ED, Lynfield R, Sawyer MH (Eds), American Academy of Pediatrics, Ithasca, IL 2021. p.876.

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Suggested parenteral antibiotic regimens for mastitis or breast abscess in infants without severe complications,* according to most frequent gram stain findings