Antimicrobial Usage for Empiric Therapy

Please see updated dosing guidelines in the Housestaff Medication Manual

Early-onset sepsis (≤72h)

Most likely bacteria to cover: E. coli (and other Gram-negative rods), GBS, Listeria.

Ampicillin  +  Gentamicin

- Check trough level prior to 3rd dose
- Add Cefotaxime or Cefepime if concern for meningitis.

Late-onset sepsis (>DOL3)

a) Central line or VP-shunt in place

Need to cover coag.-neg. Staph. and Staph. aureus (MSSA/MRSA)

First empiric choice:

Infant acts "sick": Vancomycin + Gentamicin

Infant is stable: Consider withholding Vancomycin in stable infant with single positive blood culture for coag.-neg. Staph. Repeat blood culture before initiating Vancomycin. If negative, consider first culture skin contaminant (>10%).

b) Abdominal infection / Necrotizing enterocolitis (NEC)

Most likely bacteria to cover: Gram-negative rods, anaerobes, (coag.-neg. Staph.)

First empiric choice:

Ampicillin (or Vancomycin) & Gentamicin (& Metronidazole (perforation?))
or Piperacillin/Tazobactam & Gentamicin
or Meropenem

c) Suspected or confirmed meningitis/meningoencephalitis

Most likely bacteria to cover: Gram-negative rods, GBS, Listeria, HSV

First empiric choice: Ampicillin + Gentamicin + Cefepime (or Cefotaxime)

- Add Acyclovir if concern for HSV encephalitis!

d) Possible fungal infection

Most likely fungi to cover: Candida albicans, non-albicans Candida, Malassezia

First empiric choice: conventional Amphotericin B

- Consider Fluconazole or Mycafungin if Amphotericin B not tolerated and Candida albicans. Send isolates for sensitivities (in particular non-albicans Candida)!

Ventilator-associated pneumonia

Most likely bacteria to cover: Klebsiella, Enterobacter, Serratia ("KES"), Pseudomonas

First empiric choice: Piperacillin/Tazobactam or Cefepime + Gentamicin

Consider: Vancomycin if Gram-positive cocci in clusters (coag.-neg. Staph. or MRSA?)

General considerations:

1. Need to pull all lines ASAP for sepsis with Candida, Gram-negative rods, Enterococcus, and persistent coag.-neg. Staph.! Treat 2-3 days before placing new line.

2.  Do not forget to obtain urine, CSF, surface cultures, PCR material.

3. Evaluate for metastatic foci of infection (TORCH, GBS, S. aureus, Candida) in thrombi, endocardium, retina, kidney, bones etc.

4. Be aware of tendency of cerebral abscess formation in Citrobacter koseri, Serratia marcesens, and Enterobacter sakazakii meningitis.

5.  Beware of resistance development to 3rd generation cephalosporins (due to inducible extended-beta lactamase production).

6. “Double-cover” for SPACEK (Serratia, Pseudomonas, Acinetobacter, Citrobacter, Enterobacter, Klebsiella) organisms.

7. Switch to Meropenem for infections with Gram-negative rods if no response to therapy.

8. Consult Pediatric Infectious Diseases before the horses are out of the barn.

J.-H. Weitkamp, 5/2007