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Suggested antimicrobial regimens in the management of neonatal sepsis in term and late preterm infants

	Antibiotic regimen
Empiric therapy
Early onset (<72 hours)	Ampicillin and gentamicin
Late onset (≥72 hours) – Admitted from the community	Preferred regimen – Ampicillin and gentamicin Alternative – Ampicillin and an expanded-spectrum cephalosporin (eg, ceftazidime, cefepime, or cefotaxime [where available])
Late onset (≥72 hours) – Hospitalized since birth	Gentamicin and vancomycin*
Special circumstances:
Suspected meningitis – Early onset or late onset, admitted from the community	Ampicillin, gentamicin, and an expanded-spectrum cephalosporin (eg, ceftazidime, cefepime, or cefotaxime [where available])^¶
Suspected meningitis – Late onset, hospitalized since birth	Gentamicin, vancomycin, and an expanded-spectrum cephalosporin (eg, ceftazidime, cefepime, or cefotaxime [where available])^¶
Suspected pneumonia	Ampicillin and gentamicin Alternatives: Ampicillin and expanded-spectrum cephalosporin, or Vancomycin and expanded-spectrum cephalosporin, or Vancomycin and gentamicin
Suspected infection of skin, umbilicus, soft tissues, joints, or bones (S. aureus is a likely pathogen)	Vancomycin and gentamicin, or Vancomycin, nafcillin, and gentamicin, or Vancomycin and an expanded-spectrum cephalosporin (eg, ceftazidime, cefepime, or cefotaxime [where available])
Suspected intravascular catheter-related infection	Vancomycin and gentamicin
Suspected infection due to organisms found in the gastrointestinal tract (eg, anaerobic bacteria)	Ampicillin, gentamicin, and clindamycin Alternatives: Ampicillin, gentamicin, and metronidazole or Piperacillin-tazobactam and gentamicin
Pathogen-specific therapy
Group B Streptococcus	Penicillin G
E. coli – Ampicillin-sensitive	Ampicillin
E. coli – Ampicillin-resistant	Expanded-spectrum cephalosporin (eg, ceftazidime, cefepime, or cefotaxime [where available]) Alternative: Meropenem
Multidrug-resistant gram-negative bacilli (including ESBL-producing organisms)	Meropenem
L. monocytogenes	Ampicillin and gentamicin
MSSA	Nafcillin or cefazolin
MRSA	Vancomycin
Coagulase-negative staphylococci	Vancomycin

This table summarizes our suggested antibiotic regimens for empiric and pathogen-specific therapy for neonatal sepsis. The initial choice of empiric therapy depends on the neonate's age, likely pathogens, and presence of an apparent source of infection (eg, skin, joint, or bone involvement). Local antibiotic susceptibility patterns should also be considered. For example, in centers with a high prevalence of gentamicin resistance among gram-negative isolates, an alternative aminoglycoside (eg, amikacin) may be preferred. Refer to UpToDate's topics on neonatal sepsis for additional details.

S. aureus: Staphylococcus aureus; E. coli: Escherichia coli; ESBL: extended-spectrum beta-lactamase; L. monocytogenes: Listeria monocytogenes; MSSA: methicillin-susceptible S. aureus; MRSA: methicillin-resistant S. aureus.

* A regimen of oxacillin or nafcillin plus gentamicin is reasonable if the neonate has a recent negative MRSA screening test.

¶ If there is concern for meningitis caused by a multidrug-resistant gram-negative organism, a carbapenem such as meropenem is the preferred agent for empiric therapy.

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