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Selected parenteral drug doses for infants ≤28 days of age with suspected invasive Staphylococcus aureus infection

Selected parenteral drug doses for infants ≤28 days of age with suspected invasive Staphylococcus aureus infection
Drug Regimen
Oxacillin Age ≤7 days:
  • GA ≤34 weeks: 25 mg/kg IV every 12 hours
  • GA >34 weeks: 25 mg/kg IV every 8 hours
Age 8 through 28 days:
  • GA ≤34 weeks: 25 mg/kg IV every 8 hours
  • GA >34 weeks: 25 mg/kg IV every 6 hours
Nafcillin
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
Linezolid Age ≤7 days:
  • GA ≤34 weeks: 10 mg IV every 12 hours
  • GA >34 weeks: 10 mg IV every 8 hours
Age 8 through 28 days:
  • 10 mg IV every 8 hours (independent of GA)
VancomycinΔ

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 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 on S. aureus infections in neonates for additional information about choice of therapy. Unless otherwise specified, age refers to postnatal age.
GA: gestational age; IV: intravenous; AUC: area under the curve; MRSA: methicillin-resistant S. aureus; PMA: postmenstrual age; PNA: postnatal age.
* 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.
¶ Serum creatinine concentration will take approximately five to seven 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 ays: 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
Δ Alternative dosing is suggested for clinicians/institutions who follow AUC-guided therapeutic monitoring for vancomycin for serious MRSA infections as suggested by consensus guidelines[4]; this strategy requires input from a clinical pharmacist, who will provide recommendations for initial dosing. Refer to UpToDate content on invasive staphylococcal infections in children for details of trough-guided and AUC-guid
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.
  4. Rybak MJ, Le J, Lodise TP, et al. Therapeutic monitoring of vancomycin for serious methicillin-resistant Staphylococcus aureus infections: A revised consensus guideline and review by the American Society of Health-System Pharmacists, the Infectious Diseases Society of America, the Pediatric Infectious Diseases Society, and the Society of Infectious Diseases Pharmacists. Am J Health Syst Pharm 2020; 77:835.Elk Grove Village, IL 2009. p.745.
Data from: American Academy of Pediatrics. Tables of antibacterial drug dosages. In: Red Book: 2021 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.
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