Community-acquired sepsis or septic shock in neonates and children younger than 2 months who may have meningitis
For term and preterm neonates with late onset community-acquired sepsis or septic shock (occurring after 72 hours of birth) who may have meningitis (ie not excluded by lumbar puncture), and children younger than 2 months who have community-acquired sepsis or septic shock who may have meningitis, as a 3-drug regimen, use:
1gentamicin intravenously; see Principles of aminoglycoside use for prescribing considerations and subsequent dosing gentamicin
child 1 to 2 months: 7 mg/kg for initial dose
OR
1tobramycin intravenously; see Principles of aminoglycoside use for prescribing considerations and subsequent dosing tobramycin
child 1 to 2 months: 7 mg/kg for initial dose
PLUS EITHER
1cefotaxime 50 mg/kg intravenously; for dosing frequency, see Cefotaxime intravenous dosing for neonates and children younger than 2 months with sepsis or septic shock cefotaxime
OR
1ceftriaxone (child 1 month or older) 50 mg/kg intravenously, 12-hourly ceftriaxone
PLUS with any of the above regimens
1amoxicillin intravenously amoxicillin
neonate younger than 7 days: 100 mg/kg 12-hourly
neonate 7 days or older: 100 mg/kg 8-hourly
child 1 to 2 months: 50 mg/kg 6-hourly
OR
1ampicillin intravenously ampicillin
neonate younger than 7 days: 100 mg/kg 12-hourly
neonate 7 days or older: 100 mg/kg 8-hourly
child 1 to 2 months: 50 mg/kg 6-hourly.
In children 1 month to younger than 2 months, empirical therapy for Listeria monocytogenes infection may not be required – consult local protocols, or seek expert advice to determine if amoxicillin or ampicillin may be omitted from the above regimen. If culture results are negative for Listeria monocytogenes, amoxicillin or ampicillin may be stopped.
In neonates and children suspected to have HSV infection, or neonates whose birthing parent had active genital HSV infection at birth, add aciclovir to the above regimens. Use:Australasian Society for Infections Diseases (ASID) 2022
If HSV infection is confirmed, see Neonatal herpes simplex infection for subsequent management.
For neonates and children at increased risk of MRSA infection (eg exposed to a caregiver colonised with MRSA), add vancomycin to the above regimens. Use:
vancomycin intravenously; for initial dosing, see Intermittent vancomycin dosing in young infants. vancomycin
If intravenous (or intraosseous) access cannot be rapidly established (eg within 15 minutes), the initial dose of antimicrobial therapy can be administered intramuscularly. Ceftriaxone is preferred over cefotaxime when administered intramuscularly due to its long half-life. Cefotaxime should be given rather than ceftriaxone for neonates and children younger than 2 months receiving intravenous calcium solutions (including parenteral nutrition, compound sodium lactate [Hartmann solution], lactated Ringer solution), or those with jaundice, hypoalbuminaemia, acidosis, unconjugated hyperbilirubinaemia or impaired bilirubin binding. For more information, see Practical information on using beta lactams: cephalosporins.
If intravenous (or intraosseous) access cannot be rapidly established in term and preterm neonates, and children younger than 2 months, as a 3-drug regimen, use:
1gentamicin intramuscularly; see Principles of aminoglycoside use for prescribing considerations and subsequent dosing gentamicin
child 1 to 2 months: 7 mg/kg for initial dose
OR
1tobramycin intramuscularly; see Principles of aminoglycoside use for prescribing considerations and subsequent dosing tobramycin
child 1 to 2 months: 7 mg/kg for initial dose
PLUS EITHER
1ceftriaxone 50 mg/kg intramuscularly, as a single dose while establishing intravenous (or intraosseous) access ceftriaxone
OR
2cefotaxime 50 mg/kg intramuscularly, as a single dose while establishing intravenous (or intraosseous) access cefotaxime
PLUS with one of the above regimens
1amoxicillin intramuscularly, as a single dose while establishing intravenous (or intraosseous) access amoxicillin
neonate: 100 mg/kg
child 1 to 2 months: 50 mg/kg
OR
1ampicillin intramuscularly, as a single dose while establishing intravenous (or intraosseous) access ampicillin
neonate: 100 mg/kg
child 1 to 2 months: 50 mg/kg.
Vancomycin and aciclovir cannot be given intramuscularly. If the neonate or child younger than 2 months is at increased risk of MRSA infection (eg exposed to a caregiver colonised with MRSA) or if HSV infection is suspected, seek expert advice.
Establish intravenous (or intraosseous) access before the next scheduled antimicrobial dose. There are few data on absorption and distribution of intramuscular antimicrobials in sepsis or septic shock. If switching from intramuscular ceftriaxone to intravenous cefotaxime, administer the first cefotaxime dose 12 hours after the intramuscular ceftriaxone dose.