Choice of empirical antibiotic regimen for sepsis or septic shock of unknown source in neonates and children younger than 2 months

The choice of antibiotics for sepsis or septic shock of unknown source in neonates and children younger than 2 months is complex. A regimen based on local protocols, or advice from a clinical microbiologist or infectious diseases physician improves outcomes. This is particularly important for neonates and very young children in the intensive care unit. Mortality is decreased when appropriate antibiotics are given early.

For advice on recognising sepsis and septic shock, see Identifying sepsis or septic shock.

The choice of empirical antibiotic regimen for neonates and children younger than 2 months with sepsis or septic shock is influenced by:

• the age of the child or neonate
• whether the infection was acquired in the community or in hospital
• whether meningitis has been excluded (usually by lumbar puncture).

Meningitis should be considered in neonates and children younger than 2 months being treated for sepsis or septic shock. In neonates, there should be a higher suspicion of meningitis and a lumbar puncture is usually required. Seek expert advice from a senior clinician to determine whether a lumbar puncture is required.

If a lumbar puncture is required but cannot be performed, the neonate or child younger than 2 months may need be transferred to a hospital with adequate expertise – seek expert advice.

Performing a lumbar puncture should not delay initiation of appropriate antimicrobial therapy.

The empirical antibiotic regimens in these guidelines can be used initially if local protocols are not available, or if clinical microbiology or infectious diseases advice is not immediately available. To find the right empirical antibiotic regimen for neonates and children younger than 2 months with sepsis or septic shock of unknown source, use Choice of empirical antibiotic regimen for sepsis or septic shock in neonates and children younger than 2 months.

In neonates, the choice of antibiotics is influenced by whether infection occurs within 72 hours of birth¹.

• Sepsis or septic shock that occurs within 72 hours of birth is considered to be early onset. The causative organisms are most commonly acquired from the birthing parent (eg mother). The most likely pathogens are Streptococcus agalactiae (group B streptococcus), Escherichia coli, herpes simplex virus (HSV) and Listeria monocytogenes. For empirical regimens, see Early onset sepsis or septic shock of unknown source in neonates.
• Sepsis or septic shock that occurs more than 72 hours after birth is considered to be late onset. The causative organisms may be acquired from the birthing parent or the caregiving environment. The most likely pathogens are S. agalactiae (group B streptococcus), E. coli and other gram-negative bacteria, HSV, S. aureus, coagulase-negative staphylococci and L. monocytogenes. Choice of empirical regimen is influenced by whether the neonate:
  • has been in hospital since birth
  • was admitted from the community.
• If the sick neonate is preterm, or develops sepsis more than 72 hours after birth but before discharge from hospital (eg neonates treated in an intensive care unit), management is complex – seek expert advice, and consult local protocols if available. Empirical regimens for preterm neonates are included in this topic; however, these should only be used while awaiting expert advice.

In children 1 month to younger than 2 months, choice of empirical regimen is influenced by whether the child:

• developed sepsis in hospital
• was admitted from the community.