Empiric Antibiotic Therapy In Newborn Care Units

Every nursery deserves a written antibiotic policy based on microbial culture, sensitivity, and resistance pattern. This article summarizes an empiric antibiotic therapy and referenced antibiotic doses used in antibiotic charting tool for newborns.

Early Onset Sepsis (EOS)

  • Onset of symptoms from birth to 3 days of life
  • Common microbes – E. coli, group B streptococcus (GBS), Listeria monocytogenes
  • Empiric therapy for EOS:
    • Ampicillin + Gentamicin
    • Piperacillin-tazobactam + Amikacin
  • Do not use Cefotaxime (or any other cephalosporin) for EOS:
    • Causes Vancomycin Resistant Enterococci (VRE)
    • Induces 𝛃-lactamase and extended-spectrum 𝛃-lactamase (ESBL) producing bacteria which are resistant to all 𝛃-lactam antibiotics
    • Ineffective against L. monocytogenes
    • Increases risk of invasive candidiasis

Ampicillin

ampicillin dose in newborns
Ampicillin dose in newborns [Ref: Nelson’s Pediatric Antimicrobial Therapy, 25th ed.]

Ampicillin (Meningitis)

  • Age 0 – 7 days → 50 mg/kg/dose q6h
  • Age > 7 days → 75 mg/kg/dose q6h

Gentamicin

gentamicin dose in newborns
Gentamicin dose in newborns [Ref: Cloherty and Stark’s Manual of Neonatal Care, 8th ed.]

Piperacillin-Tazobactam

piperacillin-tazobactam dose in newborns
Piperacillin-tazobactam dose in newborns [Ref: Cloherty and Stark’s Manual of Neonatal Care, 8th ed., Gomella Neonatology, 8th ed.]

Late Onset Sepsis (LOS)

  • Onset of symptoms from day 4 to 3 months
  • Empiric therapy:
    • Cefotaxime + Amikacin
    • Cefotaxime + Ampicillin ± Amikacin (suspected meningitis)

Cefotaxime

cefotaxime dose in newborns
Cefotaxime dose in newborns [Ref: Nelson’s Pediatric Antimicrobial Therapy, 25th ed.]

Cefotaxime (Meningitis)

  • Age 0 – 7 days → 50 mg/kg/dose q8h
  • Age > 7 days → 50 mg/kg/dose q6h

Amikacin

Amikacin dose in newborns
Amikacin dose in newborns [Ref: Cloherty and Stark’s Manual of Neonatal Care, 8th ed.]

Meropenem

Meropenem dose in newborns
Meropenem dose in newborns [Ref: Nelson’s Pediatric Antimicrobial Therapy, 25th ed.]

Meropenem (Meningitis)

Meropenem dose in neonatal meningitis
Meropenem dose in neonatal meningitis [Ref: Nelson’s Pediatric Antimicrobial Therapy, 25th ed.]

Miscellaneous Antibiotics

Linezolid

Linezolid dose in newborns
Linezolid dose in newborns [Ref: Nelson’s Pediatric Antimicrobial Therapy, 25th ed.]

Aztreonam

Aztreonam dose in newborns
Aztreonam dose in newborns [Ref: Nelson’s Pediatric Antimicrobial Therapy, 25th ed.]

Vancomycin

  • Suspected Coagulase-negative Staphylococci (CoNS) or S. aureus
  • Complicated illness or indwelling catheters
Vancomycin dose in newborns
Vancomycin dose in newborns [Ref: Cloherty and Stark’s Manual of Neonatal Care, 8th ed.]

Vancomycin (Meningitis)

15 mg/kg/dose q6h

Fluconazole

  • Treatment dose: 12 mg/kg/dose q24h
  • Prophylaxis dose: 6 mg/kg/dose twice weekly
  • Prophylaxis in ELBW (<1000 g birth weight) babies in nurseries with high rates (> 10%) of invasive candidiasis

Amphotericin-B Deoxycholate

1 mg/kg/dose q24h

  • Infused over 2 – 6 hours
  • Diluted to a concentration of 0.1 mg/mL in D5%

When To Stop Antibiotics?

  • Probable sepsis:
    • Send sepsis profile (CBC, CRP, PBF, and blood culture) before starting antibiotics.
    • If the newborn is clinically normal AND the first sepsis profile AND blood culture of the baby is normal, stop antibiotics.
  • Confirmed sepsis (When sepsis profile is positive and the newborn responds to antibiotics and becomes asymptomatic):
    • Gram negative sepsis: 10-14 days
    • Group B streptococcus meningitis: 14-21 days
    • Gram negative meningitis: 21 days
    • Sepsis without focus: 10 days
    • For preterm newborns <32 weeks: 10-14 days

Other Drugs

Caffeine Citrate

  • Loading dose 20 mg/kg/dose IV STAT
  • Maintenance dose 5 mg/kg/dose IV every 24 hourly

Aminophylline

  • Loading dose 8 mg/kg IV infusion over 60 minutes
  • Maintenance dose 1.5 – 3 mg/kg/dose IV every 8 hourly

Phenobarbitone

  • Loading 20 mg/kg/dose
  • Maintenance 5 mg/kg/dose IV q24h

Phenytoin

  • Loading 20 mg/kg/dose
  • Maintenance 3 mg/kg/dose IV q12h
References:
  1. [edited by] John S. Bradley, Elizabeth D. Barnett and Joseph B. Cantey. 2019 Nelson’s Pediatric Antimicrobial Therapy, 25th Edition. AAP; 2018
  2. [edited by] Eric C. Eichenwald, Anne R. Hansen, Ann R. Stark, Camilia Martin. Cloherty and Stark’s Manual of Neonatal Care, 8th ed. Wolters Kluwer; 2017
  3. [edited by] Tricia Lacy Gomella, Fabien G. Eyal, Fayez Bany-Mohammed. Neonatology : Management, Procedures, On-Call Problems, Diseases, and Drugs, 8th ed. New York: McGraw-Hill Medical, 2020
  4. [edited by] Lauren Kahl, Helen Hughes. The Harriet Lane Handbook, 21st Edition. Elsevier, 2017

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