Policy Document
Policy no. Neonatal
department (003)
Policy Owner: Farwaniya
Section location:
Hospital
Neonatology Department.
Applies to: All medical staff in Effective date: January 1,
perinatal health care .
2014
Approved by: Dr. Hatem Abdelaziz Masoud – Senior Specialist
Approved by: Dr. Rima Al-Sawan Head of the Department
Approved by: Hospital Director
Revision dates:
Notes:
Title: Antimicrobial
Policy
1
Antimicrobial Policy
Neonatal Department
Farwaniya Hospital, MOH
A) Neonatal Sepsis
1.
Early Onset
:
Occurring within first 72 hours of life
1.1
Source
:
Maternal genital tract
1.2 Organisms.
1.2.a Common: Strep agalactiae (group – B)
E.coli
Klebsiella
Enterobacter
Proteus
1.2.b Occasional: Listeria monocytogenes, Haemophilus species, Anaerobes,
Staph. Aureus
1.3 Investigation
1.3.a Predictive tests : to be done stat and to be repeated after 12 hours if
indicated :




Full blood count
WBC
I / T ratio
quotient)
Quantitative CRP
:
:
:
Abnormal shifts in WBC differentiation
< 5.0 x 109 / l
≥ 0.2 (I / T Immature to total neutrophil
:
> 16 significant
1.3.b Collection of Specimens for Culture :
(i)
Neonate :
 Blood x2 seperate samples collected from different site.
 CSF. (To exclude concomitant meningitis)
 Urine x 2 (> 24 hours of age).
 Others nasopharyngeal, deep ear and umbilical swabs, gastric aspirate
first hour/before feeding.
2
(ii)




Maternal :
Low vaginal / rectal swab for GBS.
High vaginal swab (HVS) collected for all cases with suspected sepsis,
GA ≤ 34 and /or admitted to NICU/SCBU. Copy of result to be sent to
NICU/SCBU.
Blood if mother have S/S of sepsis.
Placental + swab culture (if possible).
1.4 Antibiotic Therapy
1.4.a A combination of Ampicillin and Gentamycin * are given empiricaly
1.4.b Dose :
- Ampicillin dose 50 mg/kg/dose slow I.V. intervals as seen in table 1.
- Gentamycin as in table 2.
Table 1: Ampicillin dose intervals related to GA & PNA.
Gestational Age
GA (weeks)
Postnatal Age
PNA (days)
Interval
(Hours)
≤ 29
0 to 28
> 28
0 to 14
> 14
0 to 7
>7
All
12
8
12
8
12
8
6
30 to 36
37 to 44
≥ 45
Table 2 : Gentamycin dose and intervals related to GA & PNA
PMA
(weeks)
≤29
30 to 34
≥35
Postnatal
(Days)
0 to 7
8 to 28
≥29
0 to 7
≥8
ALL
3
Dose
(mg/Kg)
Interval
(Hours)
5
4
4
4.5
4
4
48
36
24
36
24
24
1.4.c After 48 hours:
(i)
In cases:
Clinically well, no maternal risk factors. Culture negative. Predictive tests
normal (3 values within 48 hours) , crp at day 1,2 negative : Consider withdrawing
antibiotics (after discussion with consulltant).
(ii)
In cases:
Culture positive. Ulter antibiotics according to microbial sensitivity.
1.4.d Duration of antibiotics depends on location of infection – Tab-3
Table – 3 – Duration of antibiotics of culture +ve cases.
Culture +ve site
Duration
Blood
Meningitis
Urine
Pneumonia
2 weeks
≥ 3 weeks
10 days
2 weeks
Treatment of GBS infection :
A. Bacteremia/sepsis:
- Ampicillin 150 mg/kg/day plus Gentamycin
2.5 mg/kg/day for 10 days .
B. Meningitis :
- Ampicillin 300 mg/kg/day plus Gentamycin
2.5 mg/kg/day for 14 to 21 days .
4
2
Late Onset : Occurring after the first 72 hours of life
2.1
Source:
 Nursery environment
 The mother’s genital tract.
2.2
Organisms:
2.2.1 Common





Coagulase negative Staphylococci
Klebsiella pneumonia
E.coli
Pseudomonas aeuroginosa
Enterobacter
2.2.2 UnCommon:
Staph. Aureus, Enterococcus Faccalis / Facium (group – D), Strep. Pneumoniae,
Haemophilus influenzae.,serratia.
2.2.3 Others: Organism considered in early onset sepsis (late presentation).
2.3
Collection of Specimens for Culture :
Blood x 2, Urine clean catch/supra pubic bladder aspiration CSF,
Endotracheal secretions (if ventilated)/ Nasopharengeal secretions, swabs
from sites of infection e.g. inflamed umbilicus, Stool x 3 (if NEC suspected).
2.4
Antibiotic therapy:
2.4.1 Microbial surveillance showed high resistance to our standard
second line antibiotics namely 3rd generation cephalosporine hence it was
decided to replace it with tazocin for 2 years then reevaluate the results by
surveillance study ( from 01/01/2013 to 31/12/2014 ).
Doses and intervals of tazocin are seen in tab- 4.
5
Table – 4: Tazocin doses intervals related to GA & PNA.
Gestational Age
(GA) (weeks)
Postnatal Age
(Days)
Interval
(hours)
≤29
0 to 28
>28
0 to 14
>14
0 to 7
>7
All
12
8
12
8
12
8
8
30 to 36
37 to 44
>44
2.4.1 Standard second line antibiotics is a combination of Cefotaxime(Claforan)
and Amikacin to be given empirically after doing septic work up including
lumbar puncture and blood culture .
2.4.2 Doses as seen in table 5 and 6.
Cefotaxime: 50 mg/kg/dose I.V over 30 minutes
Table 5: Cefotaxime (Claforan) doses related to GA and PNA
Postmenstrual Age
(Weeks)
Postnatal Age
(days)
Interval
(hours)
≤ 29\*
0 to 28
> 28
0 to 14
>14
0 to 7
>7
All
12
8
12
8
12
8
6
30 to 36
37 to 44
> 44
6
Table 6: Doses intervals of Amikacin* related to GA in the first week of life
PMA
(Weeks)
Postnatal
(Days)
Dose
(mg/kg)
Interval
(hours)
≤ 29*
0 to 7
8 to 28
≥ 29
0 to 7
≥8
ALL
18
15
15
18
15
15
48
36
24
36
24
24
30 to 34
≥35
2.4.3 After 72 hours:
(I)
(II)
In cases:
Cultures are negative but predictive tests, CRP, WBC count suggestive of
infection or patient clinically believed to be infected and responding to
antibiotic continues for 10 days.
In cases:
Cultures are negative , and no clinical evidence of infection withdraw
antibiotic after 72 hours (after discussion with senior Dr.).
2.4.4 When aminoglycosides* are used, blood levels should be done 1 hour
post dose and prior to medication (pre-dose) and dose adjusted
accordingly (Table – 7).
Table – 7: Drug levels of used amino glycosides*
Drug
Sampling time
Target range
Amikacin
1 hour post dose = Peak
pre-dose = trough
15 – 20 microg/ml
<4 microg/ml
Gentamicin
1 hour post dose = Peak
pre-dose = trough
6-10 microg/m
<2 microg/ml
If trough levels is too high = decrease frequency to 24 or even 36 hours.
If peak level is high = decrease dose by 10 to 30 %
7
2.4.5 In cases of Fulminant Gram-negative sepsis:
Imipenem (Tienam): is added and send another blood c/s before
changing antibiotics
Dose: 25mg/Kg/dose Q 12 hours I.V. over 30 minutes.
Or Meropenem:
Sepsis : 20 mg/kg per dose Q12 hours IV over 30 minutes.
Meningitis and infections caused by pseudomonas species:
40 mg/kg per dose Q8 hours IV infusion over 30 minutes.
2.4.6 In cases suspected coagulase negative staph sepsis on clinically +
surveillance culture:
a combination of Vancomycin and Cefotaxime (Claforan) is used
empirically.
2.4.7 In cases suspected to have pseudonmonas infection ( surveillance in
the unit showed more than one case) 2nd line antibiotics should be :
Ceftazideme ( fortum) + Amikacin. ( instead of cefotaxime , amikacin)
Ceftazideme : 30 mg/kg/ dose IV infusion by syringe pump over 30
minutes. ( table 8)
Table 8 ceftazideme ( fortum) doses related to GA and PNA
Gestational Age
GA (weeks)
Postnatal Age
PNA (days)
Interval
(Hours)
≤ 29
0 to 28
> 28
0 to 14
> 14
0 to 7
>7
All
12
8
12
8
12
8
8
30 to 36
37 to 44
≥ 45
8
3
Fungal Sepsis
3.1
Common Organisms:
3.2
Collection of specimens for culture :
Candida albicans.
Blood x 2, CSF, suprapubic urine, endotracheal secretions (in ventilated
patients), CSF serum for detection of Candida antigen ( subject to
availability).
3.3
Antimicrobial therapy:
3.3.1 Amphotericin B :
0.5 to 1 mg/kg Q 24 hours IV infusion over 2 to 6 hours
Dosage modification for renal dysfunction is only necessary if serum creatinine
increase by > 35.4mmol/L during therapy – hold dose for 2 to 5 days.
3.3.2 Flucytosine: 100 mg/kg/day if patient did not respond to (a) or as a combination with (a).
3.3.3 Liposomal amphotericin (ambisome or abelcet): subject to availability.
3.3.4 Fluconazole(Diflucan) : (CSF +ve) Meningitis suspected.
Dose: 12 mg/kg/loading dose, then 6mg/kg per dose IV infusion by syringe
pump over 30 minutes, or PO. Doses interval as seen in table – 9.
Table – 9: Fluconazole doses interval in relation to GA and PNA
Gestational Age
GA (weeks)
≤ 29
30 to 36
37 to 44
≥ 45
Postnatal Age
(days)
0 to 14
>14
0 to 14
>14
0 to 7
>7
All
9
Interval
(hours)
72
48
48
24
48
24
24
3.4
Patients at high risk of fungal infection should receive Prophylactic
Therapy Local .
3.4.1 Prophylactic: Nystatin : 1 ml (=100 000 I.U) Q 8 hours Half orally and half by
nasogastric.
3.4.2 Therapeutic: Nystatin : 1 ml (=100 000 I.U) Q 6 hours Half orally and half by
nasogastric for 3 days after disappearance of signs and symptoms.
3.4.3 Nappy: Topical Nystatin (nappy rash) Q 6 hours continue 3 days after S/S subsided.
Need also to give orally for 7 to 10 days to eradicate the candida
from the gut
3.4.4 Eyes (Keratomycosis): Corneal baths of Amphotericin B : 1mg/ml
3.4.5 Cystitis:
Bladder irrigation with Amphotesicim B : 5mcg/ml of distilled water, 3 times a day
holding for 30 min X 5 days.
10
4. Neonatal Meningitis:
It can present as focal infection usually in late onset sepsis or as part of multisystem
septicaemia.
4.1
Organisms:
 Strep. Agalactiae (Group B) 40%
 E-coli, Klebsiella 40%
 Listeria 10%Others: Haemophilus, pneumococcus, Meningococcus
4.2
Antibiotic Therapy
4.2.1 Empirically: A combination of following is given.
Inj. Ampicillin
+
Inj. Cefotaxime
+
Inj. Amikacin
:
200mg/kg/day divided q 8 hourly IV
:
100mg/kg/day divided q 12 hourly IV
:
10mg/kg followed by 7.5 mg/kg q 12 hourly IV
4.2.2 In cases: Of fulminant gram-negative septicemia Ampicillin +
Meropenem + Amikacin are given empirically instead of the above
4.2.3 Specify Therapy:
Antibiotics need be modified according to the organism and its sensitivity.
(table – 10).
4.2.4 Duration: At least 3 weeks .
11
Table – 10: Antibiotic for Neonatal Meningitis.
Organism
Antibiotic
Total daily dose
IV
Number of
doses per
24 hours
3
Group B
Streptococcus or
Pneumococcus
Penicillin or
Ampicillin
+
Gentamicin
150,000 units/kg
100mg /Kg
Listeria
Monocytogenes
Ampicillin
150mg
/Kg<1
days. 200 –
300mg/kg> 1 day
old
2-3
7.5mg /kg
7.5 mg /kg
150 mg /kg
2-3
2-3
100mg /kg
20mg /kg
4
4
+
gentamicin
E-coli and other Gentamicin +
coliforms
Cefotaxime
7.5 mg /Kg/ day
Staph aureus
Flucloxacillin
vancomycin
Strept Faecalis
Ampicillin and As above
gentamicin
Haemophilus
Cefotaxime
Pseudomonas
Gentamicin
As above
Piperacillin or 300-400 mg /kg
Ceftazidime
150 mg /kg
Coagulase
negative staph
Vancomycin
1000 units
2-3
2
3
Intrathecal
dose
1-2 mg
5mg
1-2 mg
As above
20 mg /kg /day.
3-4
3
5mg
4
NB: gentamycin is preferred in CNS infection due to better penetration of BBB
12
6
Necrotizing Enterocolitis
6.1
Associated organism:
 E.coli
 Klebsiella pneumonia
 Staph epidermidis,
 Ps auroginosa
 C.perfringens
6.2
Empirical Therapy:
6.2.1 Combination of Tazocin ( Pipracillin- Tazobactam) + amikacin
Dose of Tazocin 50 -100 mg/kg./dose as pipracillin component IV infusion by
syringe pump over 30 minutes ( table 4)
6.2.2 Metronidazole (flagyl) is added to stage III NEC with or without
Perforation.
Loading: 15mg/Kg IV/over 60 minutes.
Maintenance: 7.5mg/Kg. I.V over 60 minutes.
Doses: interval related to GA & PNA (Table – 13).
Table – 13: Metronidazol doses intervals related to GA & PNA.
Gestational Age
(GA) (weeks)
Postnatal Age
(Days)
Interval
(hours)
≤29
37 to 44
0 to 28
>28
0 to 14
>14
0 to 7>7
≤45
All
48
24
24
12
24
12
8≤
30 to 36
13
7
Urinary tract infection:
UTI is confirmed by a positive culture 104 growth of single organism,
usually with a raised WBC count. It may be associated with disseminated
sepsis.
7.1 Specimens for culture and other investigation
7.1.1 Clean urine catch ,or by catheter or by suprapubic aspiration.( Urine bag samples are
invalid ).
7.1.2 Blood culture, others as indicated
CBC - WBC count.
7.2 Antibiotic Therapy
7.2.1 Specific therapy starts only on the basis of culture and sensitivity.
7.2.2 If accompanied by suspected sepsis, empiric therapy is initiated (after
specimen collection) as in sepsis depending on age of onset ≤48 hours, or ≥ 48
hours.
8
Osteomyelitis:
8.1
Common Organisms
Staph. Aureus
Strep group B and A
Antibiotic therapy
8.2
Inj. Flucloxacillin
+
Inj. Cefotaxime
:
50-100mg/kg/day, divided q/12 hourly, IV
:
50mg/kg, q, 8 or 12 hourly, IV – Table – 5
Treatment continued at least 21 days upto 4-6 weeks. Antibiotic may be modified
according to culture and sensitivity whenever available.
14
9. Umbilical sepsis:
9.1
Sticky umbilicus
9.1.1 Investigations:
Send a swab for culture (in case infection develops).
9.1.2 Treatment:
No antibiotic, Spirit swabbing of the area, Daily cleaning/bath locally with Hibiscrub
9.2
Periumbilical infection
:
Indicated by purulent discharge ± foul smelling
with surrounding erythema
9.2.1 Sepcimens for culture
:
Blood culture x 2 and local Swab
9.2.2 Treatment
Inj. Flucloxacillin
+
Inj. Gentamycin
10.
:
25-50 mg/kg, q 6 hourly, IV
:
Table 2.
Prophylactic Antibiotics
10.1 If baby given a course of corticosteroids to help extubation or for any other
reason this must be covered with antibiotics till the end of steroid course.
10.2 Babies with insertion of catheters or central lines must be done under
complete aseptic technique and covered with prophylactic antibiotics .
15
11. Conjunctivitis
See table 14
Table – 14 – Management of Neonatal Conjunctivitis
Organism
Diagnosis
Treatment.
Maternal history
Profuse conjunctival
discharge.
Urgent Gram Stain on
pus
shows
Gramnegative
intracellular
diplococci.
Culture of
swab sent in transport
medium
I.V
penicillin
75,000
units/Kg/24 hours given in
two divided for a week. Also
penicillin eye drops hourly for
24 hours. Then 4 hourly for a
week notifiable disease.
Remember to organize
treatment for mother and
contact tracing.
No distinguishing clinical
features. May be
maternal history.
Conventional cultures can
be sterile. Antigen
detected in eye swab by
immunofluorescence.
3 – 5 days peak but may Culture of Swab
be at any time including
day 1
Systemic erythromycin
(45mg/Kg/24 hours in three
divided doses) for at least 2
weeks to prevent pneumonia.
Well absorbed orally.
Age at Presentation
Gonococcus
1 day (some recognized
in 1st week)
Chlamydia
Trachomatis
5 days or more
Others;
commonest are
Staph aureus.
E-coli,
Haemophilus,
Strep
Pneumoniae
16
Use 0.5% chloramphenicol
eye drops and eye ointment
BD x 3 days after S/S
disappear.
References & Further Readings
References & Further Readings
1.
John P, Cloherty , Ann R.. Manual of Neonatal Care. 2012 lippincott
Raven, Philadelphia.
2.
Gomella T, Douglas C . Gomella neonatology .
3.
National Health Service ( NHS ) in UK 2013-2015 .
4.
Thomas E, young, Barry M . Neofax 9th ed , 2012. Acron pub. North
Carolina.
5.
Richard E, Robert M, Hal B. Nelson Textbook of pediatrics 18th ed
2012. WB saunders .
6.
Rennie JM, Roberton NRC: Infection PP 223-265 In: Rennie,
Roberton eds. Amanual of Neonatal Intensive Care (4 Med.). Great Britain,
Arnold 2002.
7.
Hughes J.M: Guide lines for the prevention of intravascular Catheter –
Related infections Vol. 51/RR-10 2002 Aug: 1-29.
Important Web Sites:
1.
http://www.pediatrics.org/cgi/content/full/101/3/e13
2.
http://www.nd.edul~kkolberg/DesignStandards.htm
3.
http://www.cdc.gov/ncidod/hip/2bactpn.htm
4.
http://www.cac.gov/mmwr/preview/mmwrntm/rrp11va3.htm
5.
http://www.cac.gov/neidod/hip/pneumonia/2bactpn.htm
17