Neonatal infection: antibiotics for prevention and treatment

Use intravenous benzylpenicillin sodium with gentamicin as the first-choice antibiotic regimen for empirical treatment of suspected early-onset infection, unless microbiological surveillance data show local bacterial resistance patterns that indicate the need for a different antibiotic. [2012]

Give benzylpenicillin sodium in a dosage of 25 mg/kg every 12 hours. Consider shortening the dose interval to every 8 hours, based on clinical judgement (for example, if the baby appears very ill). [2012]

Give gentamicin in a starting dose of 5 mg/kg (see also recommendation 1.20.4). [2012]

When prescribing gentamicin, be aware that:

• the summary of product characteristics recommends a dosage of 4 to 7 mg/kg/day administered in a single dose

• the evidence reviewed for the guideline supports a starting dosage of 5 mg/kg every 36 hours administered in a single dose.
  
  In 2021, a dosage of 5 mg/kg every 36 hours is an off-label use of gentamicin. See NICE's information on prescribing medicines. [2012]

If a second dose of gentamicin is given this should usually be 36 hours after the first dose (for criteria for stopping antibiotics at 36 hours, see recommendation 1.21.3 in the section on treatment duration for intravenous antibiotics for early-onset neonatal infection). Use a shorter interval if clinical judgement suggests this is needed, for example, if:

• the baby appears very ill

• the blood culture shows a Gram-negative infection. [2012]

Take account of blood gentamicin concentrations when deciding on subsequent gentamicin dosing regimen (see the section on therapeutic drug monitoring for babies receiving gentamicin). [2012]

Record the times of:

• gentamicin administration

• sampling for therapeutic monitoring. [2012]

If there is microbiological evidence of Gram-negative bacterial sepsis, add another antibiotic to the benzylpenicillin sodium and gentamicin regimen that is active against Gram-negative bacteria (for example, cefotaxime). If Gram-negative infection is confirmed, stop benzylpenicillin sodium. [2012]

Give intravenous antibiotic treatment for a total of 7 days for babies with a positive blood culture or negative blood culture if sepsis has been strongly suspected. [2012]

Consider continuing intravenous antibiotic treatment for more than 7 days for babies with a positive blood culture or negative blood culture if sepsis has been strongly suspected, if:

• the baby has not yet fully recovered or

• this is advisable because of the pathogen identified on blood culture (seek expert microbiological advice if necessary). [2012]

For babies who are being treated with intravenous antibiotics because of risk factors for early-onset infection or clinical indicators of possible infection, stop antibiotics at 36 hours if:

• the blood culture is negative and

• the initial clinical suspicion of infection was not strong and

• the baby's clinical condition is reassuring, with no clinical indicators of possible infection (see box 2 for clinical indicators of possible early-onset infection) and

• the levels and trends of C-reactive protein concentration are reassuring. [2012, amended 2026]

When continuing intravenous antibiotics for longer than 36 hours despite negative blood cultures, review the need for ongoing antibiotics at least once every 24 hours, taking account of:

• the level of initial clinical suspicion of infection and

• the baby's clinical progress and current condition and

• the levels and trends of C-reactive protein concentration. [2012]

For babies born from 35+0 weeks' gestation with negative blood culture who need antibiotics for more than 36 hours because the initial clinical suspicion of infection was strong, consider switching treatment from intravenous to oral antibiotics at 36 hours or thereafter to complete the course (up to 7 days of antibiotics in total) if:

• the baby's clinical condition is reassuring, with no current clinical indicators of ongoing infection (see box 2 for clinical indicators of possible early-onset neonatal infection) and

• the levels and trends of C-reactive protein concentration are reassuring and

• the baby is tolerating oral feeds. [2026]

Use amoxicillin as the oral antibiotic, unless local bacterial resistance data indicates the need for a different antibiotic.

May 2026: Amoxicillin is licensed for neonates but not specifically for the indication of early-onset neonatal infection. BNF for Children is reviewing the recommended dosage for neonates. [2026]

Consider enabling parents or carers to treat babies on oral antibiotics at home with support from the neonatal team. [2026]

Ensure that any decisions on switching to oral antibiotics or enabling a baby to go home is agreed by a senior neonatologist or paediatrician (consultant or similar level). [2026]

Before parents or carers take a baby on oral antibiotics home, ensure that:

• they have been trained to give the baby oral antibiotics, and have given them their first dose under supervision while in hospital

• they know when and how to seek medical help from the neonatal team (for signs in babies that require medical attention, see the section on information and support for parents and carers before transferring babies home)

• any concerns they have raised are addressed

• there are no other reasons for the baby to stay in hospital. [2026]

For parents and carers of babies on oral antibiotics, provide at least 2 follow-up consultations to assess the baby's wellbeing and the need for ongoing antibiotics, including 1 consultation at the end of treatment. [2026]