Antibiotic Usage in Neonates - Guidelines and Current

practices
M Jeeva Sankar, Jhuma Sankar, Sushma Nangia

From:
Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India and
Department of Pediatrics,

Corresponding Author:
M Jeeva Sankar MD DM
Senior Research Associate
Department of Pediatrics
All India Institute of Medical Sciences
New Delhi.
Email: jeevasankar@gmail.com

Abstract:
Antibiotics are one of the most abused drugs in the neonatal unit. While appropriate usage is definitely helpful,
indiscriminate use of antibiotics could lead to emergence of multidrug resistance in previously susceptible isolates.
Adopting and implementing a rational antibiotic policy would help alleviate this problem to a significant extent. In this
article, we discuss the strategy for formulating a rational antibiotic policy for any neonatal unit. In addition, we also
review the current antibiotic protocol being followed in major neonatal units of the country.

Introduction
Antibiotics often rival oxygen as the most commonly abused drug in any neonatal intensive care unit: historically,
between 11 and 23 non-infected newborns were treated with antibiotics for every one infant with proven sepsis. 1
While appropriate usage of antibiotics helps undoubtedly in reducing the risk of deaths secondary to sepsis, their
indiscriminate use can have serious repercussions including selection of multidrug resistant bacterial pathogens,
increased incidence of fungal sepsis, etc. The key strategy in such scenario would be to have a rational antimicrobial
policy that minimizes the use of antibiotics in non-infected neonates without denying it in an infant with sepsis; it also
involves using appropriate antibiotics for an adequate duration in infected neonates.
The goal of this article is to enable the physicians involved in the care of newborns to devise a rational antibiotic
policy for their respective units based on the available information and evidence. To facilitate this process, a brief
review of the existing antibiotic policies in the major neonatal units of the country has been incorporated in the article.

Antibiotic policy in neonatal units of India: A survey

We conducted a quick survey to evaluate the current practices of antibiotic usage in major level 2/3 units across the
country (n=19). This was accomplished by sending a simple questionnaire to the concerned unit chief/consultant of
the respective units. Response was obtained from seventeen units (89.5%). The key findings from the survey are
given below:

Almost all units (16/17; 94.1%) employ sepsis screen - a panel of tests, albeit in different combinations to
rule out/rule-in sepsis in neonates with risk factors and/or non-specific symptoms

Less than half of the units (7/17; 41.2%) surveyed use a risk score for identifying the neonates who are atrisk for early onset sepsis; two units do not use a proper score but enlist the various risk factors and decide
upon further management

Three-fourth of the units (12/16; 75%) continue to use prophylactic antibiotics for neonates requiring
ventilation for respiratory distress syndrome (RDS)

A combination of third generation cephalosporin with an aminoglycoside (mostly amikacin) is used as the
first line of antibiotic therapy in about one third of the units surveyed (5/16; 31.2%). About half of the units
use piperacillin-tazobactam as the second line agent (7/16; 43.8%), vancomycin as third line, and
meropenem as the reserve drug (8/16 each; 50%)

About two-third of the surveyed units (12/17; 70.6%) would wait for 48-72 hours before changing to the next
line of antibiotics in case of non-response to the first line

Most units (13/16; 81.2%) would stop antibiotics within 48-72 hours in a neonate with clinical suspicion of
sepsis but with negative sepsis screen and blood culture and normal CSF

The survey results indicate an overall healthy trend with most units implementing a rational antibiotic policy that is
titrated to the local needs of the unit. Other significant findings from the survey have been provided at the beginning
of each section.
Rational antibiotic usage in neonates
The various issues related to the use of antibiotics in neonatal sepsis can be discussed under the following headings:
A. When to start?
B. What to start?
C. When to stop?
D. Whats the optimum route and dose?
E. Special situations

A. When to start antibiotics?

The decision to start antibiotics is usually dependent upon two factors: whether the infant is symptomatic and/or atrisk for sepsis and if the diagnostic tests suggest an infectious etiology. Both of these approaches are, however, not
infallible and are prone to errors. Nevertheless, short of other options, we might still have to follow them to decide
upon initiation of antibiotic therapy in a given infant.
Antibiotic therapy in different scenarios:

If the clinical presentation of sepsis is taken as a continuum with normal newborns at one end and a classical
presentation at the other, most neonates with suspect or at-risk for sepsis would present somewhere in the middle of
this spectrum; decision-making therefore becomes difficult in most instances (Figure 1).
Figure 1: The spectrum of neonatal sepsis

Normal newborn
Condition

Asymptomatic
No risk factor

Examples

Typical
presentation
in

Suspect or at-risk for sepsis

Definite sepsis

Asymptomatic;
Risk factor+;
Received IP
antibiotics
Mother with PPROM
for >7 days on
antibiotics

Asymptomatic;
Risk factor+;
Not received IP
antibiotics
Prematurity and
prolonged labor

Symptomatic;
Low suspicion

Symptomatic;
High suspicion

Respiratory
distress; apnea;
lethargy

Some cases of EOS

Most cases of EOS

LOS in preterm
VLBW infants;
Occasional cases
of EOS

Bulging fontanel
with seizures,
sclerema, shock ,
DIC
Community
acquired LOS

(IP, intrapartum; PPROM, preterm premature rupture of membranes; EOS, early onset sepsis; LOS, late onset sepsis)

Scenario 1: Asymptomatic neonate with presence of risk factors

Panel 1: Existing practice in major neonatal units
(n=17)

No treatment:

Treat without any sepsis screen:

5 (29.4%)

Screen and treat (if positive):

10 (58.8%)

2 (11.8%)*

This scenario typically occurs in the setting of early onset sepsis (EOS) where the mode of infection involves vertical
transmission from the mothers genital tract. The risk of sepsis in these infants is definitely higher than those without
any risk factor it varies from 10 to 25 fold for different risk factors. 2 Unfortunately, most of the infants who develop
sepsis are asymptomatic at birth; they manifest symptoms usually by 24 (~90%) to 48 hours (~100%).3, 4

Two options are available for management of these infants observation alone or actively screening with or without
antimicrobial therapy based on the perceived risk.
Observation alone: This approach involves careful monitoring of the infant until (s)he develops one or more
symptoms suggestive of sepsis. Though seems more rational, it is fraught with the danger of missing an occasional
infant who progresses to develop a fulminant disease within hours of presentation. In one study involving about 1300
neonates with risk factors for sepsis, asymptomatic status was found to reduce the probability of sepsis by about
75% (adjusted OR: 0.26; 95% CI: 0.11-0.63); however, 1% of these infants were found to be infected. 4 Considering
the facts, some authors have suggested a middle path observation alone for asymptomatic neonates born at >35
weeks of gestation and antibiotic therapy with or without screening for those born at lesser gestations.5
Screening and/or treatment for sepsis: In this approach, the infants are grouped into different risk categories based
on the presence of risk factors and managed accordingly; for example, neonates who are believed to be at high-risk
(born to mother with chorioamnionitis) are started with antibiotics pending further investigations while those with
moderate risk are treated based on the results of the sepsis screen.6
It should, however, be remembered that these recommendations are predominantly based on the evidence available
from the industrialized countries where group B streptococcus (GBS) is the predominant pathogen causing EOS.
They may not be applicable to our setting where the incidence of GBS sepsis is very low. Unfortunately, no large
scale studies are available in India that have looked at the effect of various factors on the risk of developing EOS by
using a robust prediction model. A few studies have tried to evaluate the common risk factors and develop a
predictive score for identification of EOS.7 Given the paucity of definitive data, an empirical approach has also been
recommended (Table 1).
Figure 2 outlines the management of any neonate deemed to be at-risk for sepsis based on these parameters.

Table 1: Examples of predictive risk scores for early onset sepsis

Risk score 17

Risk score 28

Risk factor

1. Low birth weight or preterm

2. Febrile illness in mother within 2 weeks prior to
delivery
3. Foul smelling and/or meconium stained amniotic fluid
4. Prolonged rupture of membranes >24 h
5. More than 3 vaginal examinations during labor
6. Prolonged and difficult delivery with instrumentation
7. Perinatal asphyxia (Apgar score <4 at 1 minute) or
difficult resuscitation

Score

1. Birth asphyxia

2. Unclean vaginal examn

3. Foul smelling liquor

4. Maternal fever

5. Prematurity

6. ROM>24 hr

7. Duration of labor > 24 hrs

Interpretation:

Interpretation:

0-3: observe clinically

Presence of > 2 risk factors: do sepsis screen

>4: Investigate

Foul smelling liquor or presence of three risk factors: start

antibiotics
Figure 2: Management of asymptomatic neonate with risk factors
Asymptomatic neonate with risk factor
Monitor pending report
Sepsis screen, Blood culture

Positive screen
Start antibiotics

Positive culture

Treat for 14 days

Negative screen
Repeat screen after 12 hrs

Negative culture

Treat (duration based

on the clinical course)

Positive screen

Antibiotic till culture report

Negative screen

Monitor

As one can infer from the figure, the algorithm relies too much on the results of sepsis screen for deciding whether to
start antibiotics or not in a given infant. Though a review on the validity of sepsis screen is beyond the scope of this

article, it suffices here to say that the predictive accuracy of a positive screen is low (about 30-40%). 9 Therefore,
many non-infected infants with positive screen are also likely to be treated with antibiotics. On the other hand, the
screen with its high negative predictive value has almost 100% ability to rule-out sepsis in at-risk neonates.6
Most sepsis screen panels combine 4-5 tests, usually a combination of WBC counts and CRP. Two such sepsis
screen panels are given in Table 2. Timing of the sepsis screen is also important it is suggested that an initial
screen should be obtained not immediately but at least 12 hours after birth. 6 Recently, some screen panels have
been modified to include cytokine assays and other adjunctive tests that could be done even in the cord blood so as
to facilitate early diagnosis of sepsis.
Table 2: Examples of sepsis screen
Screen panel 12*
1.
2.
3.
4.
5.
6.

Test
Total leukocyte count <7500 or >40000/mm3
Absolute neutrophil count <1750/mm3
Immature/total neutrophils >0.2
Immature/total neutrophils >0.4
C-reactive protein >1 mg/dL
C-reactive protein >5 mg/dL

Interpretation:
Screen positive if score is >2

Screen panel 28
Score
1
1
1
2
1
2

1.
2.
3.
4.
5.

Total leukocyte count <5000/mm3

Absolute neutrophil count <1500/mm3
Immature/total neutrophils >0.2
Micro-ESR >15 mm in 1st hour
C-reactive protein >1 mg/dL

Interpretation:
- if two or more tests are positive, infant should be
treated for possible sepsis;
- if none/one test is positive, screen to be repeated
after 12 hours (if clinical suspicion still persists).

Scenario 2: Asymptomatic infant with risk factors; received intrapartum antibiotics

This scenario is particularly relevant in units from industrialized countries where intrapartum (IP) chemoprophylaxis is
routinely administered to mothers with GBS colonization. In India where gram negative bacilli are the major
pathogens responsible for EOS, the effect of such intrapartum prophylaxis, if any, remains largely unknown.
Presently, there is no evidence to suggest that the initial work-up of these infants should in anyway be different from
those who did not receive IP prophylaxis; in one of the few studies that evaluated the risk of EOS among preterm
neonates exposed to intrapartum antibiotics, the independent risk factors found to be associated with sepsis (>3 per
vaginal examinations, chorioamnionitis, birth weight <1500g, gestation <30 weeks, male gender) were not different

from those listed before. However, since the antibiotic prophylaxis could affect the blood culture results, the decision
to stop antibiotic therapy in these infants should be based more on the clinical course than on the negative culture
report (cf. infants who did not receive IP antibiotics).
Scenario 3: Symptomatic neonate
Any neonate with clinical features suggestive of sepsis should be promptly evaluated. The clinical judgment of the
constellation of symptoms and signs should help in deciding about when to start antibiotics immediately and when to
observe and monitor closely followed by treatment if necessary. When the clinical suspicion is low typical example
is a preterm VLBW neonate developing vague symptoms like lethargy, tachycardia or even apnea in the second
week of life it is prudent to wait until the results of a septic screen and/or blood culture reports are available. Infants
manifesting with symptoms like respiratory distress in the first 24-48 hours of life also fall in this category. A chest xray along with screen results and the presence or absence of perinatal risk factors would help in ruling out sepsis.
In contrast, when the clinical suspicion is high as in neonates with community acquired sepsis (pneumonia /
meningitis) antibiotic therapy should be initiated without any delay (Figure 3).
Figure 3: Management of neonate with symptoms suggestive of sepsis
Symptomatic neonate

Low suspicion

Positive screen

Treat for 14
days

B. Choice of antibiotics

High suspicion

Investigate and treat

pending report

Negative screen

Monitor

Progression of
disease

Panel 2: Existing practice in major neonatal units

Ampicillin+
aminoglycosi
de
EOS with positive
sepsis screen
(n=16)*
Community
acquired sepsis
(n=15)*
Nosocomial sepsis
(n=17)

3rd
gen.cephal+
aminoglyc.

4 (25.0%)

3 (18.8%)

Piperacillintazobactam
+
aminoglyc.
2 (12.5%)

Others

6(40.0%)

5 (33.3%)

2 (13.3%)

Co-amoxiclav+
Aminogly.:1 (6.7%)

4 (23.5%)

5 (29.4%)

Meropenem+
amika: 3 (17.6%)
Vancomycin: 3
(17.6%)

Amika alone: 3
(18.8%)

The initial choice of antibiotics for sepsis is almost always empirical because the culture reports would be available
after only 48-72 hours. The antibiotics thus started can either be continued as such or modified based on the culture
report and/or the clinical condition of the infant.

Knowledge about the prevalent microbial flora and their

sensitivity/resistance pattern in a particular unit and the common antibiotics used in the neonatal period their sideeffects and the organisms susceptible as well as resistant to them - are essential to rationalize the empirical antibiotic
therapy for that unit.
Table 3 provides a typical example of an empirical regimen suggested for use in facility settings.10
Table 3: Suggested regimen for first line antibiotic therapy in facility settings*
Early and late onset sepsis: ampicillin plus gentamicin
Early onset meningitis: ampicillin plus gentamicin
Late onset meningitis: ampicillin, gentamicin (or amikacin), and/or cefotaxime
Suspected staphylococcal sepsis, focal skin, bone, joint infections, omphalitis: methicillin/nafcillin plus
gentamicin
For sepsis of suspected GI origin: ampicillin, gentamicin/amikacin, plus clindamycin (or piperacillin)
Nosocomial infection in setting with MRSA: vancomycin plus gentamicin (and/or ceftazidime, if high
prevalence of pseudomonas)
* Source: From the report of WHO meeting to Explore simplified antimicrobial regimens for the treatment of neonatal sepsis

Given that most organisms isolated from Indian units are resistant to both ampicillin and gentamicin 11, such regime
cannot be routinely employed in most centers. Instead, a modified empirical regime for different settings based on the
assumed resistance pattern of the common isolates is being provided here (Table 4).
Table 4: Suggested empirical regime for neonatal sepsis in different settings
Examples
Situations where resistant strains are unlikely
(e.g. community-acquired pneumonia)

Septicemia & pneumonia

Penicillin or Ampicillin
plus
Gentamicin

Situations where a few strains are likely to be

resistant to common antibiotics
(e.g. nosocomial infections in intermediate care units
that cater to stable preterm infants; also in units that
adhere to rational antibiotic therapy and avoid
indiscriminate use of broad-spectrum antibiotics)
Situations where most of the strains are likely to
be resistant
(e.g. nosocomial infections in intensive care units that
cater to high-risk, sick infants; also in units that use
broad-spectrum antibiotics indiscriminately)

Ampicillin or Cloxacillin
plus
Gentamicin or Amikacin

Meningitis
Same as for
septicemia/pneumonia
plus
Cefotaxime
Same as for
septicemia/pneumonia
plus
Cefotaxime

Cefotaxime or
Piperacillin-tazobactam or
Ciprofloxacin
plus
Amikacin;

Same as for
septicemia/pneumonia
(but avoid ciprofloxacin)

Consider Vancomycin if MRSA is

suspected.
Special situations

No improvement / worsening of clinical condition

despite appropriate first-line antibiotic therapy

Sudden outbreak of infections

Consider reserve antibiotics

(e.g meropenem, aztreonam,
cefoperazone-sulbactum)
Based on the source of outbreak and
the suspected/isolated organism (e.g.
if due to MRSA, then use
vancomycin)

(MRSA, methicillin resistant Staphylococcus aureus)

Panel 3: Existing practice in major neonatal units
3rd
PiperacillinDeciding the first, second, and gen.cephal+
third line of antibiotics:
tazobactam+
aminoglycosid aminoglyc.
e
First line (n=16)*
5 (31.2%)
1 (6.2%)

Second line
(n=16)*

Fluoroquinol.
+
aminoglycosi
de
1 (6.2%)

1 (6.2%)

7 (43.8%)

3 (18.8%)

Third line (n=16)*

3 (18.8%)

1 (6.2%)

Reserve (n=16) *

1 (6.2%)

1 (6. 2%)

Other s

Ampicillin+
Aminogly.:3 (18.8%);
Co-amoxiclav+
Aminogly.:3 (18.8%)
Cefoperazonesulbactum: 1 (6.2%);
Netilmycin*: 2 (12.5%)
Meropenem: 6
(37.5%);
Vancomycin: 8
(50.0%); Fluconazole:
1 (6.2%)
Meropenem: 8
(50.0%);

As the data from the National Neonatal Perinatal Database (NNPD 2002-03) shows, most neonatal units in India
would unfortunately fall under the third category with majority of the isolates being resistant to commonly used
antibiotics.11, 12 Therefore, it becomes essential to further elaborate the process of deciding the first line of antibiotics
in these units. In addition, the second and even the third line of drugs have to be pre-decided because of the
extremely low cultutre positive rates in these units (<30%); these antibiotics might have to be used in the event of
non-response and negative blood cultures.
Given the varied microbial flora and the diverse antimicrobial sensitivity pattern, it is practically impossible to put-forth
a single policy for all the units ; instead, we have tried to lay down broad guidelines for choosing the first line and the
reserve antibiotics for any neonatal unit:
1. First, collect the data on the prevailing flora and their sensitivity pattern of your unit for the previous 6-12
months
2. Decide the first line of antibiotics based on the following principles:
o

Identify a narrow-spectrum antibiotic which covers at least 60-70% of the three most common
organisms isolated from the unit. (Though this strategy appears counter-intuitive, it is employed
because the information from a small proportion of infants with culture positive sepsis (<30%) is

being extrapolated to other neonates for whom no information is available; also, in more than twothird of the instances, the selected agent would usually work)
o

Identify an aminoglycoside to be used with the selected agent for synergistic action again
following the same principles (in some instances, aminoglycoside alone would suffice)

Avoid using broad spectrum antimicrobials such as 3rd generation cephalosporins as the first-line
agent (unless the resistance pattern demands such regime). Using antibiotics like piperacillintazobactam might be a better choice because unlike the former, it does not select for extended
spectrum beta lactamase (ESBL) producing gram negative bacilli. Moreover, the combination of
piperacillin-tazobactam and amikacin is effective for suspected pseudomonas sepsis also.

3. Decide the next line of antibiotics based on these principles:

o

These antibiotics should be able to cover almost all the organisms isolated in the given unit.

Further categorization into second/third line and reserve drugs should depend upon other
considerations like cost, spectrum of activity, safety profile, etc.

In units with high incidence of infections with cloxacillin or methicillin resistant Staphylococcus
aureus (MRSA), vancomycin might have to be considered as a second/third line agent

Newer antibiotics like aztreonam, imipenem, and meropenem should be reserved for situations
where sensitivity of the isolate justifies their use. Aztreonam has excellent activity against gramnegative organisms while meropenem is effective against most bacterial pathogens except MRSA
and enterococcus. Imipenem is usually avoided in neonates because of the reported increase in
the risk of seizures after their use.

C. Duration of antibiotic therapy

Panel 4: Existing practice in major neonatal units

Meningitis*
Culture positive for
gram+ve organisms
Culture positive for
gram-ve organisms
(n=16)
Positive screen,
negative culture
Risk factors,
negative screen and
culture (n=16)

Once
cultures are
sterile (2-3
days)
0
0

4-7 days

7-13 days

14-20 days

3 weeks or
more

0
2 (11.8%)

0
6 (35.3%)

5 (29.4%)
8 (47.0%)

12 (70.6%)
1 (5.9%)

6 (37.5%)

10 (62.5%)

5 (29.4%)

9 (52.9%)

3 (17.6%)

13 (81.2%)

3 (18.8%)

Two units use different regimes for meningitis caused by gram+ve and gram-ve organisms
(shorter course for gram+ve)

No response from one unit

No antibiotics started in one unit

The decision to discontinue antibiotic therapy is usually based upon the results of blood culture, sepsis screen, CSF
findings and more importantly the clinical course (Table 5).
Table 5: Duration of antibiotic therapy in neonatal sepsis
Diagnosis

Duration

Meningitis (with or without positive blood/CSF culture)

21 days

Blood culture positive but no meningitis

14 days

Culture negative but definite clinical sepsis

10-14 days

Culture negative, sepsis screen positive and clinical course

consistent with sepsis

7-10 days

Culture and sepsis screen negative, but clinical course compatible

with sepsis

5.7days

The above mentioned regime is, however, empirical and not based on any solid evidence. Only a few studies have
looked at the efficacy of a shorter duration of antibiotic therapy. Engle WD showed that a four day antibiotic course
was as effective as a 7-day course in near term neonates with pneumonia.13 Recently, a study from Chandigarh
found no difference between 7 day and 14 day antibiotic course in culture positive neonatal sepsis; however, the
failure rate was found to be more in infants with S aureus sepsis treated with short course regime.14 Until more robust
evidence is available, the current policy of administering antibiotics for such long periods might have to be continued.
Antibiotic therapy can, however, be stopped after 48-72 hours in those infants who are started on antibiotics for the
presence of perinatal risk factors if the clinical course is not compatible with sepsis and the cultures are sterile.

D. Route and dose of antibiotic therapy

Either intravenous or intramuscular routes are usually preferred while treating neonatal sepsis. Oral antibiotic therapy
is avoided because of the unpredictable absorption and bioavailability especially in seriously ill neonates. Many
community based studies have successfully used oral cotrimoxazole for management of pneumonia. 15 Owing to the
paucity of data regarding use of oral antibiotics in hospital settings, it cannot be recommended presently.
The dosage, route, and the frequency of administration of commonly used antimicrobial agents are given in Table 6.
Table 6a: Dosages (mg/kg/dose) of commonly used antimicrobial agents - Aminoglycosides16
Drug

Route

Amikacin
Gentamicin
Netilmicin

IV Infusion over 30 min

IV Infusion over 30 min
IV Infusion over 30 min

<29 weeks PMA

0-7 days
18 q48h
5 q48h
5 q48h

8-28 days
15 q36h
4 q36h
4 q36h

30 to 34 weeks PMA
0-7 days
18 q36h
4.5 q36h
4.5 q36h

8-28 days
15 q24h
4 q24h
4 q24h

>35 weeks PMA

0-7 days
15 q24h
4 q24h
4 q24h

8-28 days
15 q24h
4 q24h
4 q24h

(PMA, postmenstrual age; IV, intravenous)

Table 6b: Dosages (mg/kg/dose) of commonly used antimicrobial agents (other than aminoglycosides)16
Drug

Ampicillin
Meningitis
Others
Cefotaxime
Ciprofloxacin
Cloxacillin

Route

<29 weeks PMA

30 to 36 weeks PMA

>37 weeks PMA

0-7 days

8-28 days

0-14 days

14-28 days

0-7 days

8-28 days

100 q12h
50 q12h
50 q12h
10-20 q24h
50 q12h

100 q12h
50 q12h
50 q12h
10-20 q24h
50 q8h

100 q12h
50 q12h
50 q12h
10-20 q24h
50 q12h

100 q8h
50 q8h
50 q8h
10-20 q12h
50 q8h

100 q12h
50 q12h
50 q12h
10-20 q24h
50 q 8h

100 q8h
50 q8h
50 q8h
10-20 q12h
50 q6h

IV slow push
IV Infusion over 30 min

Meropenem
Meningitis/
IV Infusion over 30 min
Pseudomonas sepsis
Sepsis due to other
organisms
Penicillin G
(Units/kg/day)
IV Infusion over 30 min
Meningitis
Others
Piperacillin +
IV Infusion over 30 min
tazobactam
Vancomycin
Meningitis
IV Infusion over 60 min
Others
(PMA, postmenstrual age; IV, intravenous)

40 q8h

40 q8h

40 q8h

40 q8h

40 q8h

40 q8h

20 q12h

20 q12h

20 q12h

20 q12h

20 q12h

20 q12h

75,000-100,000
q12h
25000 -50000
q 12h
50-100 q12h

75,000-100,000
q12h
25000 -50000
q12h
50-100 q12h

75,000-100,000
q12h
25000 -50000
q12h
50-100 q12h

75,000-100,000
q8h
25000 -50000
q8h
50-100 q8h

75,000-100,000
q12h
25000 -50000
q12h
50-100 q12h

75,000-100,000
q8h
25000 -50000
q8h
50-100 q8h

15 q18h
10 q18h

15 q12-18h
10 q12-18h

15 q12h
10 q12h

15 q8h
10 q8h

15 q12h
10 q12h

15 q8h
10 q8h

E. Special situations
Prophylactic antibiotics:
Panel 1: Existing practice in major neonatal units
(n=16)*
In neonates ventilated for respiratory distress syndrome:

No antibiotics:

4 (25%)

Only amikacin:

2 (12.5%)

Aminoglycoside+others:

10 (62.5%)

The use of prophylactic antibiotics for infants on IV fluids/TPN, meconium aspiration syndrome, or after exchange
transfusions is not recommended. An exchange transfusion conducted under strict asepsis (single use catheter,
sterile gloves, removal of catheter after the procedure) does not increase the risk of sepsis. As for antibiotic
prophylaxis in ventilated neonates is concerned, there is not enough evidence to either support or refute its use
(Cochrane review).17
Minimizing antibiotic resistance in neonatal units
Recently in his editorial titled The antibiotic crisis, Isaacs D has pointed out that unlike other countries, the situation
of antibiotic resistance in Indian neonatal units has reached crisis level.18 The reasons attributed for this phenomenon
include: not taking blood cultures before staring antibiotics, continuing antibiotics even after a negative culture report,

adding more potent broad spectrum antibiotics if the baby remains sick, and the belief that raised CRP is proof of
sepsis. It is the duty of every physician involved in the care of newborns to develop as well as implement both local
and national guidelines on antibiotic use in neonates and to ensure that the menace of antibiotic resistance does not
continue unabated.

Acknowledgement:
We greatly acknowledge the following experts for their prompt response to the
questionnaire on Antibiotic usage in neonatal units of India: Dr Paul VK, Dr Saili A,
Dr Ramji S, Dr Mathur NB, Dr.? from SGRH (New Delhi); Dr .PGI, Dr Chawla D
(Chandigarh), Dr Nanavati R, Dr Gupta G (Mumbai), Dr Mathai, Dr Vaidya U (Pune),
Dr Bhatia (Varanasi), Dr Shenoi A (Bangalore), Dr Jain N (Trivandrum), Dr Murki S
(Hyderabad), Dr Singh A (Kolkata), Dr Jain S (Indore).

References:

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Carter J, Hobel CJ, Leake RD, Anthony BF, Thibeault DC, Ross IB, Drage JS. Perinatal bacterial infection after prolonged
rupture of amniotic membranes: an analysis of risk and management. J Pediatr 1984;104:608-13.
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