This handout is for neonatal sepsis — early-onset (< 72 h) + late-onset (72 h - 28 d). Your care team identified this based on: neonate (≤ 28 d) with temperature instability (t < 36 °c or ≥ 38 °c rectal), poor feeding, lethargy, apnoea, hypoglycaemia, jaundice progression, or respiratory distress (aap puopolo 2018).
Other reasons your team may use this plan: maternal risk factor: gbs-positive without intrapartum prophylaxis or chorioamnionitis or prom > 18 h or preterm < 37 wk or intrapartum maternal temperature ≥ 38 °c (cdc verani 2010 pmid 21088663; aap puopolo 2018); preterm neonate < 32 wk gestation in nicu with new-onset clinical deterioration — late-onset sepsis high-pretest cohort (stoll nichd 2011 pmid 21873694); neonate ≤ 28 d with vesicles / seizures / hypothermia / unexplained transaminitis / encephalopathy / maternal genital hsv — empiric acyclovir until hsv excluded (kimberlin pediatrics 2013).
Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.
| Medication | Starting dose | How | When | What it does |
|---|---|---|---|---|
| ampicillin | 200 mg/kg/day divided q8h (DOL 0-7) or q6h (DOL > 7); meningitis dose: 300 mg/kg/day divided q6-8h | IV | q6-8h | Covers Listeria (cephalosporins do not) + GBS + sensitive E. coli (AAP Puopolo 2018) |
| gentamicin | Term ≥ 35 wk: 4 mg/kg q24h; late-preterm 30-34 wk: 4.5 mg/kg q36h; preterm < 30 wk: 5 mg/kg q48h (extended interval per gestational age) | IV | q24-48h extended interval | Gram-negative synergy with ampicillin; extended-interval dosing per Neofax + AAP Puopolo 2018; trough monitoring before 3rd dose |
| cefotaxime | 50 mg/kg/dose IV q8-12h (gestational + chronological-age dependent); meningitis: 50 mg/kg q6-8h | IV | q6-12h | CNS penetration superior to gentamicin; use INSTEAD OF gentamicin if meningitis suspected. AVOID ceftriaxone in neonates < 28 d (bilirubin displacement + calcium-IVF interaction) (AAP Puopolo 2018; FDA 2009) |
| acyclovir | 60 mg/kg/day divided q8h IV (20 mg/kg/dose) for ≥ 35 wk; reduced interval q12h if preterm < 35 wk | IV | q8h (q12h preterm) | Cover neonatal HSV until excluded; high mortality if missed (Kimberlin Pediatrics 2013 AAP Red Book 2024). Duration: 14-21 d SEM; 21 d CNS/disseminated; suppressive PO acyclovir × 6 mo post-treatment for CNS disease (Kimberlin NEJM 2011) |
| vancomycin | 15 mg/kg/dose IV; interval per gestational + chronological age (q6h-q18h) | IV | per nomogram | Add-on for MRSA / CoNS / severe SSTI source; AUC target 400-600 (Rybak IDSA 2020) with caveat — limited neonatal data |
Plan: Neonatal sepsis empiric antibiotics — by onset (early < 72 h vs late 72 h - 28 d) + comorbidity
Contact your care team if any of the following happen:
Call 911 or go to the nearest emergency room right away if you have:
Outpatient peds visit within 24-48 h of discharge for high-risk; 1-week visit for all; growth + feeding tracking + developmental milestones; immunization catch-up per cause (PCV / Hib not yet age-eligible at < 28 d but tracked for first dose); hearing screen if meningitis (AABR + audiology referral); developmental peds referral at 6-12 mo if functional decline / neurological sequelae; family education on return precautions; vaccination of family contacts (Tdap, influenza, COVID-19 per ACIP); breastfeeding support; PT/OT if neurological sequelae; PICS-p / PICU-Family syndrome screening at 1-3 months for caregivers + child.
Guideline: AAP Clinical Report — Puopolo et al, Management of Neonates ≥35 wk With Suspected/Proven Early-Onset Sepsis, Pediatrics 2018 (PMID 30455342) + CDC Verani 2010 GBS prophylaxis (PMID 21088663) + Phoenix pediatric sepsis criteria JAMA 2024 (PMID 38245890) + FEAST fluid-bolus trial NEJM 2011 (PMID 21615299). Neonatal HSV (Kimberlin), candidiasis (IDSA), and AAP Red Book cited by name.