Neonatal infection: antibiotics for prevention and treatment

  • NICE guideline
  • NG195
  • Published: 
  • Last updated: 
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Investigations before starting antibiotics for early-onset or late-onset neonatal infection

NICE has published early value assessment guidance on Genedrive MT-RNR1 ID Kit for detecting the MT-RNR1 m.1555A>G genetic variant to guide use of aminoglycoside antibiotics (including gentamicin) and prevent hearing loss in babies. This technology can be used in the NHS, while more evidence is generated. The guidance will be reviewed after the generation period (3 years). See NICE's early value assessment on Genedrive MT-RNR1 ID kit. 

1.13 Cultures, microscopy and C-reactive protein

1.13.1

When starting antibiotic treatment in babies who may have neonatal infection, perform a blood culture before giving the first dose. [2021]

1.13.2

Measure baseline C-reactive protein concentration when starting antibiotic treatment in babies who may have neonatal infection. Use this together with any subsequent readings to assess the likelihood of infection and response to treatment. [2021]

1.13.3

Do not routinely perform urine microscopy or culture as part of the investigations for early-onset neonatal infection, or late-onset neonatal infection for babies in neonatal units. [2021]

1.13.5

Do not perform skin swab microscopy or culture as part of the investigations for neonatal infection if there are no clinical signs of a localised infection. [2021]

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on cultures, microscopy and C-reactive protein before starting antibiotics.

Full details of the evidence and the committee's discussion are in evidence review G: investigations before starting treatment for late-onset neonatal infection.

1.14 Lumbar puncture

1.14.1

If it is safe to do so, perform a lumbar puncture to obtain a cerebrospinal fluid sample when:

  • there is a strong clinical suspicion of neonatal infection or

  • there are clinical symptoms or signs suggesting meningitis. [2021]

1.14.2

Treat and stabilise any of the following before performing a lumbar puncture:

  • unprotected airway

  • respiratory compromise

  • shock

  • uncontrolled seizures

  • bleeding risk. [2024]

1.14.3

Do not perform lumbar puncture if there is:

  • extensive or rapidly spreading purpura

  • infection at the lumbar puncture site

  • risk factors for an evolving space-occupying lesion

  • any of these symptoms or signs, which might indicate raised intracranial pressure:

    • new focal neurological features (including seizures or posturing)

    • abnormal pupillary reactions

    • a progressive and sustained or rapid fall in level of consciousness. [2024]

1.14.4

Measure blood glucose in babies immediately before lumbar puncture, so that the cerebrospinal fluid to blood glucose ratio can be calculated. [2024]

For a short explanation of why the committee made the 2021 and 2024 recommendations and how they might affect practice, see the rationale and impact section on lumbar puncture.

Full details of the evidence and the committee's discussion are in evidence review G: investigations before starting treatment for late-onset neonatal infection and evidence review L: investigating and diagnosing suspected bacterial meningitis with cerebrospinal fluid parameters.

Cerebrospinal fluid investigations in babies with suspected bacterial meningitis

1.14.5

Perform the following cerebrospinal fluid investigations in babies with suspected bacterial meningitis:

  • red and white cell count and cell type (including differential white cell count)

  • total protein

  • glucose concentration (to calculate cerebrospinal fluid to blood glucose ratio)

  • microscopy for bacteria (using gram stain)

  • microbiological culture and sensitivities

  • polymerase chain reaction (PCR) for relevant pathogens. [2024]

1.14.6

Store the remaining cerebrospinal fluid in case more tests are needed. [2024]

1.14.7

Ensure that cerebrospinal fluid, cell counts, total protein and glucose concentrations are available within 4 hours of lumbar puncture. [2024]

1.14.8

When interpreting the results of cerebrospinal fluid investigations, take into account:

  • red cells in the sample, which may suggest blood contamination or a different diagnosis

  • whether earlier antibiotics may have reduced the diagnostic reliability of these investigations. [2024]

1.14.9

Interpret cerebrospinal fluid results using standard age-appropriate threshold values (taking into account factors such as gestational age, chronological age, birth weight, and earlier antibiotic use or suspected immunodeficiency). [2024]

1.14.10

Interpret cerebrospinal fluid results in babies alongside the clinical presentation and maternal history. [2024]

1.14.11

If cerebrospinal fluid results are abnormal, consider alternative viral, mycobacterial, fungal or non-infectious causes as well as bacterial meningitis. [2024]

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on cerebrospinal fluid investigations in babies with suspected bacterial meningitis.

Full details of the evidence and the committee's discussion are in evidence review L: investigating and diagnosing suspected bacterial meningitis with cerebrospinal fluid parameters.