Medication Summary
The antibiotics commonly used to treat neonatal sepsis include ampicillin, gentamicin, cefotaxime, vancomycin, erythromycin, and piperacillin. The choice of antibiotic agents should be based on the specific organisms associated with sepsis, the sensitivities of the pathogen, and the prevailing nosocomial infection trends in the nursery. Viral infections, such as herpes and fungal infections, can masquerade as bacterial infections.
Antibiotics, Other
Class Summary
Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting. Neonatal doses for antibiotics may be based on several variables (eg, postmenstrual age [PMA], postnatal age, and weight).
Ampicillin
Ampicillin is a beta-lactam antibiotic that is bactericidal for susceptible organisms, such as group B Streptococcus (GBS), Listeria, non–penicillinase-producing Staphylococcus, some strains of Haemophilus influenzae, and meningococci. Some publications recommend ampicillin (in combination with gentamicin) as first-line therapy for suspected sepsis in the newborn.
Gentamicin
Gentamicin is an aminoglycoside that is bactericidal for susceptible gram-negative organisms, such as Escherichia coli and Pseudomonas, Proteus, and Serratia species. It is effective in combination with ampicillin for GBS and Enterococcus. Some publications recommend gentamicin (in combination with ampicillin) as first-line therapy for suspected sepsis in the newborn.
Cefotaxime (Claforan)
Cefotaxime is a third-generation cephalosporin with excellent in vitro activity against GBS and E coli and other gram-negative enteric bacilli. Therapeutic concentrations can be achieved in serum and cerebrospinal fluid (CSF). Concern exists that emergence of drug-resistant gram-negative bacteria may occur more rapidly with cefotaxime coverage than with traditional penicillin and aminoglycoside coverage.
Vancomycin
Vancomycin is a bactericidal agent that is effective against most aerobic and anaerobic gram-positive cocci and bacilli. It is especially important in the treatment of methicillin-resistant Staphylococcus aureus (MRSA) and is recommended when coagulase-negative staphylococcal sepsis is suspected. However, therapy with rifampin, gentamicin, or cephalothin may be required in cases of endocarditis or CSF shunt infection with coagulase-negative staphylococci.
Chloramphenicol
Chloramphenicol has been shown to be effective in the treatment of highly resistant bacterial meningitis. It inhibits protein synthesis by binding reversibly to 50S ribosomal subunits of susceptible organisms, which, in turn, prevents amino acids from being transferred to growing peptide chains.
Oxacillin
Oxacillin is a bactericidal antibiotic that inhibits cell wall synthesis. It is used in the treatment of infections caused by penicillinase-producing staphylococci. It may be given as initial therapy when a staphylococcal infection is suspected.
Piperacillin
Piperacillin is an acylampicillin with excellent activity against Pseudomonas aeruginosa. It is also effective against Klebsiella pneumoniae, Proteus mirabilis, B fragilis, Serratia marcescens, and many strains of Enterobacter. It is most often given in combination with the beta-lactamase inhibitor tazobactam.
Erythromycin base (Erythrocin, Ery-Tab, EryPed, E.E.S.)
Erythromycin is a macrolide antimicrobial agent that is primarily bacteriostatic and is active against most gram-positive bacteria, such as Neisseria species, Mycoplasma pneumoniae, Ureaplasma urealyticum, and Chlamydia trachomatis. It is not well concentrated in the CSF.
Trimethoprim/sulfamethoxazole (Bactrim DS, Septra DS)
Trimethoprim-sulfamethoxazole has been shown to be effective in the treatment of highly resistant bacterial meningitis. Trimethoprim-sulfamethoxazole inhibits bacterial growth by inhibiting the synthesis of dihydrofolic acid. Trimethoprim-sulfamethoxazole should not be used if hyperbilirubinemia and kernicterus are of concern in the newborn.
Antivirals, Other
Class Summary
A viral infection, such as that from herpes simplex virus (HSV), may masquerade as bacterial sepsis. At the onset of the infection, treatment must be initiated promptly to effectively inhibit the replicating virus.
Acyclovir (Zovirax)
Acyclovir is used for treatment of mucosal, cutaneous, and systemic HSV-1 and HSV-2 infections.
Zidovudine (Retrovir)
Zidovudine is a thymidine analogue that inhibits viral replication. It is used to treat patients with HIV infection.
Antifungals, Systemic
Class Summary
Fungal infections can masquerade as bacterial infections or may appear at the end of prolonged antibacterial therapy. Their mechanism of action may involve an alteration of RNA and DNA metabolism or an intracellular accumulation of peroxide, which is toxic to the fungal cell.
Fluconazole (Diflucan)
Fluconazole is used to treat susceptible fungal infections, including oropharyngeal, esophageal, and vaginal candidiasis. It is also used for systemic candidal infections and cryptococcal meningitis. Fluconazole has fungistatic activity. It is a synthetic oral antifungal (broad-spectrum bistriazole) that selectively inhibits fungal CYP450 and sterol C-14 alpha-demethylation, which prevents conversion of lanosterol to ergosterol, thereby disrupting cellular membranes.
Amphotericin B (AmBisome)
Amphotericin B is used to treat severe systemic infections and meningitis caused by susceptible fungi, such as Candida and Aspergillus species, Histoplasma capsulatum, and Cryptococcus neoformans. This agent is a polyene produced by a strain of Streptomyces nodosus; it can be fungistatic or fungicidal. Amphotericin B binds to sterols, such as ergosterol, in the fungal cell membrane, causing intracellular components to leak and subsequent fungal cell death.
Liposomal amphotericin B (AmBisome) may be considered for patients with systemic fungal infections resistant to amphotericin B or for patients with renal or hepatic failure. This product consists of amphotericin B within a single-bilayer liposomal drug delivery system.
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Neonatal sepsis. Incidence of early-onset and late-onset invasive group B Streptococcus (GBS) disease. Graph from Verani JR, McGee L, Schrag SJ, for the Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention (CDC). Prevention of perinatal group B streptococcal disease--revised guidelines from CDC, 2010. MMWR Recomm Rep. 2010 Nov 19. 59 (RR-10):1-36. Online at: https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5910a1.htm.
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Neonatal sepsis. Indications and nonindications for intrapartum antibiotic prophylaxis to prevent early-onset group B streptococcal (GBS) disease. Table from Verani JR, McGee L, Schrag SJ, for the Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention (CDC). Prevention of perinatal group B streptococcal disease--revised guidelines from CDC, 2010. MMWR Recomm Rep. 2010 Nov 19. 59 (RR-10):1-36. Online at: https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5910a1.htm.
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Neonatal sepsis. Recommended regimens for intrapartum antibiotic prophylaxis for prevention of early-onset group B streptococcal (GBS) disease. Diagram from Verani JR, McGee L, Schrag SJ, for the Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention (CDC). Prevention of perinatal group B streptococcal disease--revised guidelines from CDC, 2010. MMWR Recomm Rep. 2010 Nov 19. 59 (RR-10):1-36. Online at: https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5910a1.htm.
