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Recommended Antimicrobial Dosage Schedules for Neonates

Jeffrey L. Segar, MD, Chetan A. Patel, and Sarah B. Tierney, PharmD.


Peer Review Status: Internally Peer Reviewed 3/26/12

Drug Dosage Major Indications / Remarks
Acyclovir 20 mg/kg/dose q 8 hr IV
Administer over 1 hour
Herpes Simplex & Varicella.
Increase dosing interval with <34 wk
gestation or with significant renal /
hepatic failure
Treat localized infections for 14 days;
disseminated or CNS infections for 21
days.
Amikacin* Give IV or IM
PMA
(weeks)
Postnatal
(days)
Dose
(mg/kg)
Interval
(hrs)
!29 0 to 7
8 to 28
"29
18
15
15
48
36
24
30 to
34
0 to 7
"8
18
15
36
24
"35 ALL 15 24
Administer over 30 minutes
Gram negative enteric bacteria
peak 20-30, trough 2-5 mcg/ml
Usually used in combination with a beta-
lactam antibiotic.
Amoxicillin 20 mg/kg/dose q HS PO UTI prophylaxis
Amphotericin B test dose: 0.1 mg/kg IV
initial dose: 0.25 mg/kg IV
increment : 0.125 - 0.25 gm/kg/d IV
maintenance dose: 1 mg/kg/d qd or 1.5
mg/kg/d qod IV
Administer over 2-6 hours
Most systemic fungal infections &
severe superficial mycoses. Decreases
renal blood flow / GFR; Monitor renal /
hepatic status closely.
total dose: 15-30 mg/kg
Ampicillin

Mild/Moderate infection: 100 mg/kg/dose
IV
Meningitis:400 mg/kg/d q 8-12 hr IV
See Table 2 for dosing interval
Administer by IV push over 3-5 minutes
Group B streptococcus, enterococcus,
E coli, Listeria monocytogenes
Aztreonam 30 mg/kg/dose IV or IM
Administer slow IV push over 5-10
minutes
See Table 2 for dosing interval
Gram negative organisms. Generally
used in combination with ampicillin
(empirical treatment of sepsis) or an
aminoglycoside (for synergism against
Pseudomonas and Enterobacteriaceae).
Check serum glucose 1 hour after
administration. Aztreonam contains L-
arginine so adequate amounts of glucose
must be provided to prevent
hypoglycemia.
Caspofungin 25 mg/m
2
(or approximately 2 mg/kg) IV
per dose q24 hours
Administer over 1 hour
Antifungal agent for refractory Candida
or invasive Aspergillosis refractory or
intolerant to other therapies.
Max concentration 0.5 mg/ml diluted in an
NS product; not dextrose
Cefazolin 25 mg/kg/dose IV slow push or IM
See Table 2 for dosing interval
1
st
generation cephalosporin. Gram +
cocci ; may cause false positive urine
reducing substance. Poor CNS
penetration.
Cefepime !28 days: 30 mg/kg/dose q 12 hr IV or IM
>28 days: 50 mg/kg/dose q 12 hr IV or IM
Meningitis and severe infections: 50
mg/kg/dose q 8 hr IV or IM
Administer IV over 30 minutes
4
th
-generation cephalosporin for serious
gram-positive and gram-negative
infections, especially Pseudomonas
aeruginosa. Drug distributes widely in
body tissues and fluids.
Cefotaxime 50 mg/kg dose IV or IM
See Table 2 for dosing interval
Administer IV over 30 minutes
3
rd
-generation cephalosporin. Treatment
of gram-negative enteric bacteria.
Penetrates well across BBB and good for
use in meningitis
Cefoxitin 30 mg/kg/dose IV or IM
See Table 2 for dosing interval
Administer IV over 30 minutes
2
nd
-generation cephalosporin with
enhanced activity against anaerobic
bacteria. Poor CNS penetration.
Treatment usually limited to skin, intra-
abdominal, and urinary tract infections.
Ceftazidime Sepsis 0-4 weeks: 30 mg/kg/dose IV
Meningitis: 50 mg/kg/dose IV
See Table 2 for dosing interval
Administer IV over 30 minutes
3
rd
-generation cephalosporin for gram-
negative esp. Pseudomonas: Consider
two antibiotics with positive
Pseudomonas cultures. Synergistic with
aminoglycosides.
Ceftriaxone Sepsis/Disseminated gonococcal infections:
50 mg/kg q 24 hours IV or IM
Meningitis: 100 mg/kg loading dose than
80 mg/kg q 24 hours IV or IM.
Uncomplicated gonococcal ophthalmia: 50
mg/kg (max 125 mg) once IV or IM.
Administer IV over 30 minutes
3
rd
-generation cephalosporin for gram-
negative bacteria and gonococcal
infection. Widely distributes. Not
recommended for use in neonates with
hyperbilirubinemia. Concurrent
administration with calcium-containing
products in neonates is contraindicated.
Cefuroxime 15 mg/kg/dose qHS PO UTI Prophylaxis
Cephalexin 10-20 mg/kg/dose qHS PO UTI Prophylaxis
Can alternate with or change to Bactrim
at 2 months of life
Clindamycin 5 to 7.5 mg/kg/dose IV, IM, or PO
See Table 2 for dosing interval
Administer IV over 30 minutes

Gram-positive cocci and bacteroides.
Widely distributes to most tissues, esp
the lungs. Poor CSF penetration.
Psuedomembranous colitis most serious
adverse effect bloody diarrhea, fever
Erythromycin 10-15 mg/kg q 6-12 hr PO
Do NOT administer IM
Chlamydia and Mycoplasma
Risk of hypertrophic pyloric stenosis is
increased 10-fold in neonates < 2 weeks
who receive oral erythromycin for
pertussis prophylaxis.
Fluconazole Treatment: 12 mg/kg loading dose, then 6
mg/kg IV or PO
Prophylaxis: 3 mg/kg/dose 2x/wk IV or PO
Thrush: 6 mg/kg LD, then 3 mg/kg/dose qd
PO
Gest Age
(weeks)
PostNatal
(days)
Interval
(hours)
!29 0 to 14
>14
48
24
>30 0 to 7
>7
48
24
Administer IV over 60 minutes
Antifungal for Candida species. Monitor
renal and hepatic function. Extended
dosing interval when SCr >1.3. PO/IV
both well-absorbed and distributes
widely, incl. CSF. May increase levels of
phenytoin and rifampin. Use with
Cisapride contraindicated.
Flucytosine 12.5 to 37.5 mg/kg/dose q 6 hours PO
Increase dosing interval if renal
dysfunction is present.
Antifungal for Candida, Cryptococcus.
Must be used in combination with
amphotericin B of fluconazole due to
development of resistance. Toxicities
include impaired renal function, fatal
bone marrow depression, hepatitis,
severe diarrhea, rash.
Ganciclovir 6 mg/kg/dose q12 hours IV
Treat for a minimum of 6 weeks if possible
Decrease dose by # for neutropenia (<500
cells/mm
3
). Discontinue therapy if
neutropenia does not resolve after dose
reduction.
Administer over 60 minutes
Prevention of progressive hearing loss
and lessening of developmental delays in
symptomatic congenital CMV.
Gentamicin* Give IV or IM
PMA
(weeks)
Postnatal
(days)
Dose
(mg/kg)
Interval
(hrs)
!29 0 to 7
8 to 28
"29
5
4
4
48
36
24
30 to
34
0 to 7
"8
4.5
4
36
24
"35 ALL 4 24
Administer IV over 30 minutes

Gram negative aerobic bacilli;
Usually used in combination with a beta-
lactam antibiotic. Administer as a
separate infusion from penicillin-
containing compounds.
Ototoxic effects synergistic with lasix.
Need to monitor serum levels:
Trough: < 2, ideal 0.5 to 1.0; Peak: 5-
12 mg/L
For high trough levels, increasing dosing
interval to next higher level is usually
sufficient - always recheck levels again
after adjusting dosage/interval
Imipenem/Cilastatin 20-25 mg/kg/dose q12 hrs IV
Administer over 30 minutes
Non-CNS infections caused by
Enterobacteriaceae and anaerobes
resistant to other antibiotics. Seizures
common with meningitis and severe
renal dysfunction.
Isoniazid Treatment: 10-15 mg/kg/day PO qd or
divided BID
Prophylaxis: 10 mg/kg PO qd
Mycobacteria
Lamivudine 2 mg/kg/dose q 12 hours PO for 1 week
following birth
Used in combination with zidovudine.
Prevention of mother-to-child HIV
transmission when no other therapy
during pregnancy.
Linezolid 10 mg/kg/dose q8 hours PO or IV
Preterm and < 1 week give q12 hours.
Administer IV over 30 minutes.
Gram-positive organisms, incl. MRSA,
refractory to vancomycin and other
antibiotics. Not used for empiric
therapy.
Meropenem Sepsis: 20 mg/kg/dose IV
Gest Age
(weeks)
Postnatal
(days)
Interval
(hours)
!32 0 to 14
>14
12
8
>32 0 to 7
>7
12
8
Meningitis/Pseudomonas: 40 mg/kg/dose
q8 hr
Administer IV over 30 minutes
Multidrug-resistant gram-negative,
gram-positive, and anaerobic organisms.
Methicillin

25 - 50 mg/kg/dose IV or IM
< 2 kg: < 7 d: q12 h; > 7 d: q 8 h
> 2 kg: < 7 d: q 8 h; > 7 d: q 6 h
Penicillinase-producing Staphylococcus
aureus. Use the higher doses for
meningitis
Metronidazole Loading dose: 15 mg/kg IV/PO
Maintenance dose: 7.5 mg/kg IV/PO
PMA
(weeks)
Postnatal
(days)
Interval
(hours)
!29 0 to 28
>28
48
24
30 to 36 0 to 14
>14
24
12
37 to 44 0 to 7
>7
24
12
"44 ALL 8
Administer IV over 60 minutes
Anaerobic infections; begin maintenance
dose 48 h after load in preterm infants &
after 24 h in term infants.
Mezlocillin 50 - 100 mg/kg/dose IV / IM
See Methicillin for dosing schedule
Pseudomonas, Group B Strep, most
Klebsiella pneumoniae and Serratia
marcescens
Mupirocin Apply small amount topically to affected
area q8 hours for 5-14 days.
MRSA topical infections. Do not apply
to the eye. May cover with gauze.
Nafcillin Usual: 25 mg/kg/dose IV
Meningitis: 50 mg/kg/dose IV
See Table 3 for dosing interval
Administer IV over 15 minutes
Penicillinase-producing Staphylococcus
aureus. Use nafcillin for renal
dysfunction pts.
Nevirapine 2 mg/kg PO once at 48 to 72 hours of age.
If mother did not receive intrapartum
single-dose nevirapine, administer 2 mg/kg
as soon as possible after birth.
Used ONLY in combination with
zidovudine in treatment of neonates born
to HIV-infected women who had no
therapy during pregnancy.
Nystatin Preterm: 0.5 mL PO q6 hours Mucocutaneous candida infections.
Term: 1 mL PO q6 hours
Apply topically with swap to each side of
mouth. Use for length of antibiotic therapy
and continue for 24 hours after
discontinuation of antibiotic therapy,
especially in infants <1500 grams.
Prophylaxis against invasive fungal
infections in VLBW infants. Do not
need if using fluconazole.
Oxacillin 25 mg/kg/dose IV or IM
Meningitis: 50 mg/kg/dose IV or IM
See Table 3 for dosing interval
Administer IV over 10 minutes
Penicillinase-producing Staphylococcus
Aureus. Interstitial nephritis.
Penicillins See Table 3 for dosing interval Non-producing Penicillinase organisms
! Pen G: Meningitis 75,000 - 100,000 IU/kg/dose IV or IM
Administer IV over 30 minutes
See Methicillin for dosing schedule
! Pen G: Sepsis 25,000 - 50,000 IU/kg/dose IV or IM
Administer IV over 15 minutes

For Group B Strep sepsis: 200,000 IU/kg/d
in divided doses and 400,000 IU/kg/d in
divided doses with meningitis


Treatment of susceptible organisms:
streptococci , cong. syphilis, gonococci


! Benzathine
50,000 units/kg one dose, IM only
50,000 U/kg IM q wk x 3 doses
Syphilis (No clinical findings and only if
follow-up cannot be ensured)
Syphilis > 1 yr. in mother
! Procaine 50,000 units/kg q day, IM only Syphilis
Piperacillin 50 to 100 mg/kg/dose IV or IM
See Table 3 for dosing interval
Administer IV over 30 minutes
Gram-positive, gram-negative, anaerobic
incl. Pseudomonas and Group B Strep.
Piperacillin-Tazobactam
(Zosyn)
50 to 100 mg/kg/dose IV or IM
See Table 3 for dosing interval
Administer IV over 30 minutes
Gram-positive, gram-negative, anaerobic
incl. Pseudomonas and Group B Strep.
Non-CNS infections.
Ribavirin Dilute 6 gm in 300 ml sterile water.
Administer by aerosol over 12 - 18 hr
daily for 3 - 7 days
Respiratory syncytial virus (severe
herpes). Most effective if begun early in
course of illness. May worsen respiratory
distress. Should be administered in a
well-ventilated room. Women of child-
bearing age should not administer.
Rifampin PO: 10 -20 mg/kg q24 hr.
IV: 5 - 10 mg/kg q 12 hr
Administer IV over 30 minutes
Mycobacteria; causes red discoloration
of body secretions. Must be used in
combination with vancomycin or
aminoglycosides for persistent
staphylococcal infections. Causes
orange/red discoloration of body
secretions. Potent inducer of P450.
Ticarcillin -Clavulanate 75-100 mg/kg/dose IV
See Table 3 for dosing interval
Administer IV over 30 minutes

Pseudomonas
may cause decreased platelet
aggregation, bleeding diathesis,
hypernatremia, hypocalcemia, increased
AST
Tobramycin* See Gentamicin for dosing schedule
Administer IV over 30 minutes
Aerobic gram-negative bacilli (e.g., E
coli, Pseudomonas, Klebsiella)
Need to monitor levels
Trough: < 2 mg/L, ideal 0.5 -1.0. Peak:
5 - 12 mg/L
Trimethoprim-
Sulfamethoxazole
(Bactrim)
Prophylaxis: 2 mg/kg qHS PO
Treatment: 4 mg/kg q12 hours PO
UTI caused by E.coli, Klebsiella,
Enterobacter, Proteus
Contraindicated < 2 months
Valganciclovir 16 mg/kg/dose PO q12 hours.
Treat for a minimum of 6 weeks. Prodrug
of ganciclovir.
Neutropenia common.
If ANC<500 hold until >750
If ANC<750, reduce dose by 50%
If ANC<500 again, discontinue.
Vancomycin* 10-15 mg/kg/dose IV
PMA
(weeks)
Postnatal
(days)
Interval
(hours)
!29 0 to 14
>14
18
12
30 to 36 0 to 14
>14
12
8
37 to 44 0 to 7
>7
12
8
"45 ALL 6
Administer IV over 90 minutes
Methicillin-resistant staphylococci (e.g.,
S aureus and S epidermidis) and
penicillin-resistant pneumococci. Note:
Red man syndrome results from rapid IV
infusion.
Need to monitor serum levels
Trough: 5-10 mg/L; Peak: 25 - 40 mg/L
Give 15 mg/kg/dose if CNS infection
Zidovudine IV: 1.5 mg/kg/dose over 60 minutes
PO: 2 mg/kg/dose.
Do not give IM
Begin treatment 6-12 hours after birth and
continue for 6 weeks.
Treatment of HIV infection in
combination with other antiretroviral
agents.
Initiation of therapy after age 2 days is
not likely to be effective.
* Serum drug level monitoring recommended. See document Use of Drug Monitoring Levels in the NICU for
appropriate procedures.

Table 2: Dosing Interval Chart
Gest. age Postnatal age Interval (q)
< 29 wk 0 to 28 d 12 hr
> 28 d 8 hr
30 to 36 wk 0 to 14 d 12 hr
> 14 d 8 hr
"37 wk 0 to 7 d 12 hr
> 7 d 8 hr


Table 3: Dosing Interval Chart
PMA
(weeks)
Postnatal
(days)
Interval
(hours)
!29 0 to 28
>28
12
8
30 to 36 0 to 14
>14
12
8
37 to 44 0 to 7
>7
12
8
"45 ALL 6

Table 4: Usual Therapeutic Range
PEAK (g/ml) TROUGH (g/ml)
Gentamicin 5-12 0.5-1.0
Tobramycin 5-12 0.5-1.0
Kanamycin 20-25 5-10
Amikacin 20-30 2-5
Vancomycin 25-40 5-10
These data represent usual starting and maintenance doses for seriously compromised infants or LBW
weight premature infants (< 2 kg or <34 wk. gestation) and full-term infants.
Monitoring of serum drug levels will assist in optimizing dosage adjustments, particularly with changing
organ function as the newborn matures or recovers from the initial illness.
Optimum time to obtain levels is 30 min. prior to next dose for trough levels, and 30 minutes after
completion of IV infusion for peak levels.
With high serum levels, usually an increase in interval of administration is warranted rather than lowering
of individual dose, although both may be necessary in some neonates.

References
1. Young TE, Mangum B. Neofax A manual of drugs used in neonatal care. 23rd edition, Columbus, Ohio;
Ross Laboratories, 2010..
2. Johnson KB. The Harriet Lane Handbook. 13th edition. Mosby - Year Book, Inc., St Louis, MO, 1993
Brown & Campoli-Richards, 1989; (4) Beretz & Tato, 1988; and (5) Remington & Klein, 1990.
3. MICROMEDEX. Accessed online 2012. Updated annually.
4. Taketomo CK, Hodding JH, Kraus DM. Lexi-Comp:Pediatric Dosage Handbook. Accessed online 2012.
Updated annually.

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