Parenteral antibiotics | Infants ≤28 days | Infants >28 days |
Gram-positive cocci | ||
CA-MRSA not a concern (one of the following) | ||
Nafcillin or oxacillin |
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CA-MRSA a concern (one of the following) | ||
Clindamycin¶ |
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VancomycinΔ |
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Gram-negative organisms (one of the following) | ||
Gentamicin§ |
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Amikacin§ |
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Cefotaxime¥ (if available) |
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Ceftazidime¥ (if cefotaxime not available) |
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Ceftriaxone¥‡ (if cefotaxime not available) |
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Gram stain not available or no organisms seen | ||
CA-MRSA not a concern | ||
Nafcillin or oxacillin, plus one of the following:
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CA-MRSA a concern | ||
Clindamycin¶ or vancomycin, plus one of the following:
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AUC: area under the curve; CA-MRSA: community-acquired methicillin-resistant Staphylococcus aureus; GA: gestational age; IV: intravenously; PMA: postmenstrual age; PNA: postnatal age.
* 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.◊ 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.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, Ithasca, IL 2021. p.876.
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