Rationale and impact
These sections briefly explain why the committee made the recommendations and how they might affect practice. They link to details of the evidence and a full description of the committee's discussion.
Information and support for parents and carers of babies at increased risk of neonatal infection
Recommendations 1.1.1 and 1.1.2
Why the committee made the recommendations
The 2021 committee decided that 2 of the information and support recommendations for parents and carers of babies at increased risk of early-onset neonatal infection from the 2012 guideline on early-onset neonatal infection were also applicable to parents and carers of babies who may develop late-onset infection.
How the recommendations might affect practice
These recommendations have been adapted from the 2012 guideline on early-onset neonatal infection, reflecting standard practice. As such, they are not expected to have a substantial impact on practice.
Information and support for parents and carers of babies treated for neonatal infection
Why the committee made the recommendation
The 2021 committee decided that 1 of the information and support recommendations for parents and carers of babies treated for early-onset neonatal infection from the 2012 guideline on early-onset neonatal infection was also applicable to parents and carers of babies treated for late-onset infection.
How the recommendation might affect practice
This recommendation has been adapted from the 2012 guideline on early-onset neonatal infection, reflecting standard practice. As such, it is not expected to have a substantial impact on practice.
Information and support for parents and carers of babies being treated for bacterial meningitis
Recommendations 1.3.1 to 1.3.3
Why the committee made the recommendations
The 2024 committee made recommendations based on evidence on the views of parents and carers, and based on their knowledge and experience.
The committee emphasised the need to discuss the issues covered in the recommendations with parents and carers of babies with bacterial meningitis, to give them the chance to ask questions, and to repeat information over time. This is because people may be distressed and unable to ask questions or understand information when their baby is first admitted to hospital.
Emotional and pastoral support is recommended for parents and carers because of the severe impact meningitis can have on a baby.
How the recommendations might affect practice
The recommendations largely reflect current practice and they should not have a significant resource impact.
Information and support for parents and carers before transferring babies home
Why the committee made the recommendation
The 2012 guideline on early-onset neonatal infection recommended that parents and carers of babies with risk factors for early-onset infection should be given verbal and written information on the signs and symptoms of infection. This is particularly important when the baby already has risk factors that indicate they may develop infection.
However, the 2021 committee noted that any baby can develop an infection, even if they are not identified as high risk at the time of discharge. The committee, therefore, thought it was important that all parents and carers should be given information about the signs and symptoms of neonatal infection before their baby is discharged from hospital.
The committee also wanted to ensure that the signs of infection listed in the recommendation were written in simple language that families could understand, rather than using clinical terminology. Therefore, examples of the most common breathing problems experienced by babies with neonatal infection were added to the recommendation.
How the recommendation might affect practice
This recommendation has been adapted from the 2012 guideline on early-onset neonatal infection, reflecting standard practice. As such, it is not expected to have a substantial impact on practice. Expanding the recommendation so that advice is given to all parents and carers will mean that more families will be aware of the signs of infection and will know to seek medical help if their baby develops any of them.
When to offer antibiotics during labour to prevent early-onset neonatal infection
Recommendations 1.6.1 to 1.6.5
Why the committee made the recommendations
No new evidence from 2012 to 2021 was identified. The 2021 committee extended the recommendation on antibiotics for group B streptococcus from the 2012 guideline on early-onset neonatal infection to cover women, trans men and non-binary people who had colonisation in a previous pregnancy. This was because group B streptococcus colonisation in a previous pregnancy greatly increases the chance of being colonised in future pregnancies. The committee was concerned about treatment not being offered because of a false negative test result, and so they decided to specify that a negative test should be from enrichment culture or polymerase chain reaction (PCR) on rectovaginal swab samples. Although some tests may have higher false positive rates, all women, trans men and non-binary people with positive tests should be treated as if they have group B streptococcus colonisation so that no babies who are at higher risk of infection are missed.
For women in pre-term labour and women with a clinical diagnosis of chorioamnionitis, there was no evidence identified on the effects on intrapartum antibiotics on the number of neonatal infections. However, antibiotics did reduce the number of maternal infections in women in pre-term labour. The committee also agreed that pre-term labour and chorioamnionitis are important risk factors for neonatal infection, so intrapartum antibiotics are very likely to reduce the risk to the baby. Chorioamnionitis is a serious infection that needs to be treated with antibiotics to prevent maternal harm. The committee thought that it was important to make recommendations for antibiotic treatment that would simultaneously treat maternal infection and prevent early-onset group B streptococcal infection in the baby to make the best use of antibiotics.
The committee retained the recommendations on using benzylpenicillin sodium as first-choice antibiotic from the 2012 guideline. Based on their knowledge and experience, gentamicin and metronidazole are also now recommended for women, trans men and non-binary people with chorioamnionitis, because chorioamnionitis can be caused by Gram positive or negative aerobic and anaerobic bacteria, so clinicians need to use broad-spectrum antibiotics that are effective against both. Once-daily dosing for gentamicin was recommended based on the knowledge and experience of the committee because 8 hourly dosing has additional monitoring requirements and would need additional nursing time for administration.
The committee also provided guidance on alternatives for women, trans men and non-binary people with a penicillin allergy, based on their knowledge and experience. The committee amended the 2012 recommendation on antibiotic alternatives to penicillin. They changed the recommended antibiotic from clindamycin because there is evidence of resistance to group B streptococcus emerging with clindamycin, meaning that this antibiotic should no longer be used routinely. Based on their knowledge and experience, the committee recommended a cephalosporin with activity against group B streptococcus as an alternative for people with a penicillin allergy that was not severe, and vancomycin or an alternative antibiotic with activity against group B streptococcus in the case of severe penicillin allergy. The committee was aware of the possibility of allergic reaction to cephalosporins in people with a history of penicillin allergy. For people with a history of penicillin allergy that was not severe they thought that this risk was small and was outweighed by the benefits of using cephalosporins to treat chorioamnionitis and prevent neonatal infection. They noted that cephalosporins should be used with caution in this population. Cephalosporins were not recommended in the case of severe penicillin allergy because of an increased chance of a severe allergic reaction to cephalosporins. Severe penicillin allergy refers to a history of allergy to penicillin with effects that are clearly likely to be allergic in nature such as anaphylaxis, respiratory distress, angioedema or urticaria.
How the recommendations might affect practice
Many of the recommendations remain the same as in the 2012 guideline on early-onset neonatal infection. The recommendations on intrapartum antibiotics have been extended to cover women, trans men and non-binary people:
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in pre-term labour without prelabour rupture of membranes
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with chorioamnionitis and
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with group B streptococcus colonisation in a previous pregnancy.
However, these changes reflect current practice, as many of these women, trans men and non-binary people already receive intrapartum antibiotics.
The committee expected that the recommendation on intrapartum antibiotics for chorioamnionitis would have the greatest impact on clinical practice. There is currently variation in which antibiotics are given for women, trans men and non-binary people with chorioamnionitis, with some units prescribing broad-spectrum antibiotics to treat maternal infection and benzylpenicillin sodium to prevent infection in the baby. Recommending a combination of narrow-spectrum antibiotics for women, trans men and non-binary people without an allergy to penicillin is likely to reduce the use of broad-spectrum antibiotics, which will improve antibiotic stewardship.
When to offer immediate birth to prevent early-onset neonatal infection
Why the committee made the recommendation
The evidence suggested that immediate delivery can result in a reduced risk of a baby developing neonatal infection when a woman, trans man or non-binary person is between 34 and 37 weeks' gestation and has prolonged prelabour rupture of membranes and a positive test result for group B streptococcus. The evidence did not indicate any significant harms to the baby from choosing immediate delivery over expectant management. Therefore, the committee decided that, given the potential serious consequences of a baby developing neonatal infection, a recommendation in favour of immediate delivery was important. This was further supported by the economic evidence, which showed not only a clinical benefit to immediate delivery but also lower associated costs in comparison to expectant management, which has increased antenatal costs and higher rates of infections.
The committee made a recommendation for research on the impact of neonatal infection on the health-related quality of life for parents or carers. This information was not available and would have improved how well the economic model truly reflected the costs and health consequences of neonatal infection.
How the recommendation might affect practice
This recommendation could increase the number of women, trans men and non-binary people who are offered immediate delivery when they have both prolonged prelabour rupture of membranes and a positive test for group B streptococcus. This in turn could reduce the number of babies who need to be treated for neonatal infection and also reduce the number of women, trans men and non-binary people who need to be monitored throughout the expectant management period. The exact impact of these recommendations will vary between those hospitals where group B streptococcus screening and testing is more routinely performed and those where it is not. Recommendations on group B streptococcus screening were outside of the scope of this guideline. An economic model suggested that increasing the number of people offered immediate delivery would reduce costs overall.
Antimicrobial-impregnated catheters for reducing risk of late-onset neonatal infection
Why the committee made the recommendation
There were only 2 studies looking at antimicrobial-impregnated catheters in newborn babies:
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One study looked at rifampicin-miconazole-impregnated catheters. These provided no benefit over standard catheters. In addition, they are more expensive than standard catheters.
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The other study looked at silver-zeolite-impregnated catheters. They showed some benefit compared with standard catheters, but the study was small and the committee had concerns about its quality. It was also conducted in Italy, and there are differences in clinical practice and infection rates between Italy and the UK.
The committee agreed they could not recommend antimicrobial-impregnated catheters based on the available evidence. The recommendation against the use of rifampicin-miconazole-impregnated catheters was made on the basis of the evidence that they provide no additional benefit over a standard catheter, and not because of any safety concerns over their use. There is a wider range of antimicrobials that can be used to impregnate catheters than have currently been investigated in newborn babies and uncertainty over which type of impregnated catheter is the most effective and whether monotherapy or the use of more than one antimicrobial would provide the most benefits. To address the shortage of evidence they made recommendations for research on impregnated catheters.
How the recommendation might affect practice
The recommendation will reduce the use of rifampicin-miconazole-impregnated catheters. However, antimicrobial-impregnated catheters are not commonly used for newborn babies, so this should have a limited impact.
Identification and assessment of risk factors for early-onset neonatal infection before birth
Recommendations 1.9.1 and 1.9.2
Why the committee made the recommendations
The 2021 committee agreed that the recommendations from the 2012 guideline on early-onset neonatal infection still reflected current best practice so did not need to be changed. These recommendations apply to all women, trans men and non-binary people with risk factors, including those who decline antibiotics, or those who either do not receive antibiotics or receive their first dose of antibiotics shortly before birth because of precipitate birth. As such, any women, trans men and non-binary people with risk factors should be monitored throughout labour, and these factors should be taken into account when assessing the risk of infection in the baby. See the rationale and impact section on assessing and managing the risk of early-onset neonatal infection after birth for an explanation of the changes to risk factors listed in box 1.
How the recommendations might affect practice
The recommendations have not changed.
Assessing and managing the risk of early-onset neonatal infection after birth
Recommendations 1.10.1 to 1.10.5
Why the committee made the recommendations
In 2026, evidence from 3 studies showed that the risk of early-onset neonatal infection increased as the time between prelabour rupture of membranes (PROM) at term and birth increased. The 2026 committee agreed to amend the risk factor in box 1 about rupture of membranes at term to refer to the time between rupture and birth rather than prelabour rupture and onset of labour. This reflected their view that whether membranes rupture before or after onset of labour is irrelevant and that is it the overall time between rupture and birth that is important for the risk of early-onset neonatal infection. The evidence was inconclusive in identifying a specific time interval at which the risk of early-onset neonatal infection significantly increased. So, using their clinical experience, the committee decided to keep this at more than 24 hours.
In 2021, confirmed prelabour rupture of membranes without any associated timeframe was removed from box 1 because the 2021 committee decided that it was covered by other risk factors listed.
The 2021 committee based their recommendations on evidence on the accuracy of clinical decision models for early-onset neonatal infection, as well as evidence on individual neonatal and maternal risk factors.
As there was only limited new evidence in 2021, the framework for making antibiotic decisions after birth, involving red flags and other risk factors or clinical indicators of infection, has been retained from the 2012 guideline. The 2021 committee selected the red flag risk factors and clinical indicators as those that, based on their clinical experience, need immediate treatment. Non-red flag risk factors and clinical indicators are those that can have causes other than neonatal infection and therefore do not always signal the need for immediate treatment.
In 2021, 'parenteral antibiotics during, before or after labour for confirmed or suspected bacterial infection (such as septicaemia)' was removed from the list of risk factors in box 1. Since the 2012 guideline, awareness of the risks of maternal sepsis has increased with a focus on early treatment with antibiotics. Including parenteral antibiotics as a red flag risk factor had led to more babies being prescribed antibiotics even when maternal infection was not strongly suspected. For this reason it was removed. Antibiotic use in babies can result in them being unnecessarily exposed to the side effects associated with antibiotics, such as nephrotoxicity, as well as increasing their length of stay in hospital. Increased antibiotic use is also associated with an increase in the development of antibiotic resistance.
In 2021, the inclusion of chorioamnionitis and intrapartum fever in box 1 was changed to list them as separate rather than combined risk factors because intrapartum fever has other potential causes. This change means that babies of women, trans men and non-binary people with both chorioamnionitis and intrapartum fever receive antibiotics (see below for subsequent changes to these risk factors).
In 2026, the risk factor of 'intrapartum fever higher than 38°C if there is suspected or confirmed bacterial infection' was changed to 'suspected or confirmed maternal sepsis in the intrapartum or early postpartum period'. This was done to focus on the wider signs and symptoms of sepsis (other than just a specific temperature measurement), in the intrapartum as well as the early postpartum period.
In 2021, the risk factor related to chorioamnionitis was changed to 'clinical diagnosis of chorioamnionitis' based on the committee's experience that diagnosis during the intrapartum period is usually based on clinical signs. However, in 2026, concerns were raised that this wording had caused confusion leading to a baby not being assessed because chorioamnionitis had been suspected but not confirmed. Therefore, a decision was made to revert to the original wording of 'suspected or confirmed chorioamnionitis'.
Invasive group B streptococcal infection in a previous baby and maternal group B streptococcal colonisation, bacteriuria or infection in the current pregnancy have been combined into a single risk factor, because having a previous baby with invasive group B streptococcal infection increases the risk of future colonisation and infection, but does not confer additional risk if infection, bacteriuria or infection in the current pregnancy is already known about.
The need for mechanical ventilation of babies, which was previously a red flag clinical indicator of possibly early-onset neonatal infection for pre-term babies, and a non-red flag clinical indicator for term babies has been merged into 1 red flag. The committee agreed that mechanical ventilation is a clinical indicator of possible early-onset neonatal infection regardless of prematurity, and so they decided to merge these into 1 red flag clinical indicator, which did not refer to whether a baby was born pre-term or at term.
There was uncertainty about how well the Kaiser Permanente neonatal sepsis calculator identified true cases of early-onset infection, because the studies included very few cases of infection that were confirmed by blood culture. This was a problem for the framework for making antibiotic decisions after birth outlined in the 2012 guideline on early-onset neonatal infection as well, but the 2021 committee believed that the framework was more conservative and would lead to more antibiotics being prescribed than the Kaiser Permanente calculator (both appropriately and inappropriately). Evidence on the Kaiser Permanente neonatal sepsis calculator suggests that it is good at correctly identifying babies without neonatal infection, so reducing the amount of antibiotics that are prescribed unnecessarily. However, given the very serious consequences of missing an infection, the committee preferred the conservative approach from the framework in the 2012 guideline, with some amendments as outlined. However, as the evidence does not clearly show 1 option to be better and some UK centres currently use the Kaiser Permanente calculator, they also recommended this as an alternative, but only in the context of a research or audit project. By using the Kaiser Permanente calculator as part of an audit, centres will be able to collect detailed data on the use of the tool within NHS practice, including the number of babies who correctly received treatment, those who received antibiotics unnecessarily, and any who were not recommended antibiotics but did have infection. This information will provide a more detailed understanding of the effectiveness and safety of the Kaiser Permanente calculator which can be used to inform decisions on its use in future updates of this guideline.
The 2021 committee decided to specify that the Kaiser Permanente calculator should only be used for babies who are being cared for in a neonatal unit (neonatal intensive care units, local neonatal units and special care units), transitional care or a postnatal ward. The committee highlighted how it would be more difficult to collect the information needed for the audit in other settings. They did not think the calculator should be recommended for use in the emergency department, as babies who are brought in from home are likely to already be showing signs of being unwell and therefore need more immediate treatment than babies who are being assessed for risk of infection in a neonatal unit. In these cases, waiting to consult the calculator could instead delay treatment. The committee also thought that the calculator was not appropriate for use in a midwife-led unit or freestanding midwifery unit as there is currently no evidence that has used the calculator in these settings.
To address the limited evidence, the 2021 committee made a recommendation for research on the accuracy of clinical prediction models for early-onset neonatal infection.
How the recommendations might affect practice
The 2026 revised wording for the risk factor for early-onset neonatal infection of rupture of membranes more than 24 hours before a term birth could increase the number of neonates requiring monitoring for early-onset infection, although current practice is already largely aligned with this so no significant change in practice or resource impact is expected. There could be an increase in the number of pregnant women, trans men and non-binary people opting for induction of labour as soon as possible after rupture of membranes rather than expectant management.
The 2026 revised wording in relation to the risk of factor on maternal sepsis should ensure that suspected (or confirmed) maternal sepsis in the early postpartum period will lead to the baby being assessed for early-onset neonatal infection.
Some centres use the Kaiser Permanente neonatal sepsis calculator as an alternative, and the recommendations may increase the number of centres who use this calculator in the context of a research or audit project. Evidence in 2021 suggested that this may reduce the number of babies who are unnecessarily given antibiotics, but there was substantial uncertainty about how well the calculator identified true cases of infection. If an increase in use of the Kaiser calculator resulted in more cases of infection being missed, this could increase costs associated with treating neonatal infections, as well as the very serious impact on the baby and their families.
Reducing the number of babies being given antibiotics may reduce costs for the NHS, both by reducing prescriptions and by reducing the amount of time babies and women, trans men and non-binary people spend in hospital.
Babies being monitored for possible early-onset neonatal infection
Why the committee made the recommendation
No evidence was found that related specifically to this topic, and the 2021 committee agreed that the recommendation from the 2012 guideline on early-onset neonatal infection still reflected current best practice so did not need to be changed.
How the recommendations might affect practice
The recommendation has not changed.
Assessing or reviewing babies for late-onset neonatal infection
Recommendations 1.12.1 to 1.12.3
Why the committee made the recommendations
The committee did not feel that there was sufficient, high-quality evidence for any individual model to make a recommendation on clinical prediction models for late‑onset neonatal infection. Instead, they recommended a review of the individual risk factors that may predict a baby's risk of having or developing late-onset neonatal infection.
Although there was evidence on a number of tools aimed at predicting late-onset neonatal infection, the committee did not think that there was sufficient, high quality, evidence including external validation to recommend any of them for use in practice. Most of the evidence was not from recent studies, the models were not readily available as web-based tools or in other formats that could be easily used by clinicians and it was thought that implementing them would have needed considerable changes in clinical practice.
Given the limited evidence currently available for prognostic models for late‑onset infection, the committee decided that they should make a recommendation for research on clinical prediction models for late-onset neonatal infection. The recommendation is designed to encourage the development of new models to identify babies at risk of late-onset neonatal infection as well as promoting the validation of these models and evaluation of their effects on practice. This should help to improve the understanding of the factors associated with late-onset neonatal infection so that committees can make recommendations on this area in future guideline updates.
With limited evidence on prognostic models, the committee agreed that it was instead important for clinicians to be aware of the clinical indicators and risk factors for late-onset neonatal infection. There was very limited evidence on maternal risk factors for late-onset infection and so the recommendations were based on the risk factors and signs and symptoms in the baby. The committee decided that the list of high-risk criteria from the risk stratification tool in NICE's guideline on suspected sepsis in under 16s (table 1) covered the most important indicators that clinicians in both community and specialist settings should be aware of. They included the recommendation to seek early advice from a paediatrician to highlight the importance of early treatment if any of the main clinical indicators are present. Early specialist advice was thought to be particularly important when caring for babies in the community as they need to be taken to hospital and admitted before treatment can begin, while babies who are on a neonatal unit can be monitored and treated more quickly. It was agreed that in addition to clinical indicators, it was also important to highlight potential risk factors for infection. This will help to ensure that babies who are at greater risk for infection are closely monitored for the presence of any of the clinical indicators. The committee also recommended that clinicians should think about infection in the other babies when one baby from a multiple birth has infection. Evidence was not found on this, but the committee thought that it was in line with current best practice because of the risk that all the babies from the pregnancy will have the same risk of infection.
There was very limited evidence on the signs and symptoms of infection. The committee was aware of existing recommendations on clinical indicators of infection in NICE's guideline on suspected sepsis in under 16s and so it considered this information when deciding on recommendations. It was agreed that the high-risk indicators listed in the sepsis in under 16s guideline were an accurate reflection of the committee's experience with babies who develop late-onset infection. Parental or carer concern over changes in behaviour was added to the list of high-risk criteria as this was highlighted as an important indicator of potential infection for babies in the community. Other potential clinical indicators were discussed, but the committee was concerned about the risk of over-treatment if too many clinical indicators were listed in the recommendation, especially if some of those indicators could have causes other than neonatal infection. The committee decided that the signs included in the recommendation were those that were most likely to indicate infection and therefore the most important to consider when assessing whether a baby may need treatment.
How the recommendations might affect practice
The recommendations are consistent with current practice and therefore a large resource impact is not anticipated. The table of clinical indicators may increase awareness of when a baby is at greater risk of late-onset neonatal infection. This may increase the number of babies who receive early treatment in hospital and reduce the negative effects and costs associated with infection.
Healthcare professionals working on a neonatal or paediatric ward are already likely to be aware of the risk factors that were identified. As such, the recommendations are helpful to reinforce the knowledge of these clinicians about the risk factors but may not have a substantial effect on current practice in a hospital setting.
Cultures, microscopy and C-reactive protein before starting antibiotics
Recommendations 1.13.1 to 1.13.5
Why the committee made the recommendations
The 2021 committee reviewed the evidence for late-onset neonatal infection. As this lined up with the evidence from the 2012 guideline on early-onset neonatal infection, the committee amended the 2012 recommendations to cover all neonatal infection.
Blood culture is the current 'gold standard' for identifying neonatal infection. However, babies with infection sometimes have a negative blood culture. The committee agreed that blood cultures should be taken before starting antibiotics but recognised that babies often need treatment before results are available because of the timeframe for this (hours or days) and the fact that delaying antibiotics can lead to complications or death.
Evidence for using C-reactive protein (CRP) to detect late-onset infection showed it can improve the accuracy of diagnosis when used in combination with blood culture. However, it is not accurate enough to be used as an alternative to blood culture. Furthermore, a single CRP measurement is not sufficient to diagnose infection because other factors can raise CRP levels.
The committee agreed to amend the 2012 recommendation to measure baseline CRP when starting antibiotics for early-onset infection to apply to late-onset infection too. They also covered using CRP trends to assess likelihood of infection and response to treatment.
No evidence for late-onset infection was identified that supported using urine culture or skin swabs in the neonatal unit. These tests were also not recommended in the 2012 guideline on early-onset neonatal infection and so the committee decided to recommend against their use for babies with late-onset infection in neonatal units. However, they also discussed how urine culture can be an important test for babies in a paediatric ward if a urinary tract infection is suspected, so included a recommendation which supported its use in babies with late-onset infection who are being cared for outside of neonatal units. This is consistent with the recommendations from NICE's guideline on urinary tract infection in under 16s.
How the recommendations might affect practice
The recommendations are not expected to have a major impact on practice as they reflect the procedures currently followed in most hospitals.
Lumbar puncture
Recommendations 1.14.1 to 1.14.4
Why the committee made the recommendations
There was limited evidence in 2021 on lumbar puncture specifically for late-onset infection. However, lumbar puncture is the 'gold standard' test for identifying meningitis, and it was recommended in the 2012 guideline on early-onset neonatal infection. The committee extended this recommendation to cover both early-onset and late-onset neonatal infection, as they felt that the benefits of identifying meningitis outweighed the risks of the procedure.
Antibiotics can affect the results of cerebrospinal fluid tests, so lumbar puncture needs to be performed before antibiotics when possible. The 2024 committee did not recommend a specific timeframe for performing lumbar puncture because there was concern that it would be interpreted as a hard cutoff. The key timeframe is the 1-hour timeframe for giving antibiotics, but clinical judgement is needed for decisions on how to fit lumbar puncture around this. For example, for some people it may be safe to delay the antibiotics by slightly longer than 1 hour, if this would allow a lumbar puncture to be performed first.
The 2024 committee used their experience to highlight situations that need treating or stabilising before a lumbar puncture, because these are potentially life-threatening and present a greater risk than delayed meningitis investigations.
How the recommendations might affect practice
Lumbar punctures can often be performed more quickly on acute medical wards than in emergency departments. Because of this, hospitals may need to be able to urgently transfer people with suspected bacterial meningitis out of emergency departments (following stabilisation). Hospitals may also need to streamline their processes so that acute medical wards can perform lumbar punctures within the 1‑hour timeframe for giving antibiotics.
Cerebrospinal fluid investigations in babies with suspected bacterial meningitis
Recommendations 1.14.5 to 1.14.11
Why the committee made the recommendations
There was evidence on various cerebrospinal fluid investigations for diagnosing bacterial meningitis:
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studies looked at multiple thresholds for white cell count, finding that it was at least moderately sensitive and specific at most thresholds, and very specific and sensitive at some thresholds
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overall, the evidence showed that protein concentration was at least moderately sensitive and specific
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gram staining and culture was very specific for identifying all causes of bacterial meningitis
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there was a large, consistent body of evidence showing that PCR was at least moderately sensitive and very specific for identifying particular causes of bacterial meningitis.
The committee highlighted that cerebrospinal fluid cell counts, total protein and glucose concentrations are important for clinical decision making and to guide antibiotic treatment, and agreed that these results should be available within 4 hours.
It is important to look at the whole clinical picture and take a full clinical history, including maternal history for babies aged 28 days or under. This is because there are factors that may reduce the reliability of cerebrospinal fluid investigations. Based on their knowledge and experience the committee highlighted the most important of these factors.
Age-appropriate threshold values for cerebrospinal fluid should be used. Values for some parameters (such as protein and cell counts) are higher in newborn babies than in older babies and children.
The committee highlighted the need to consider alternative diagnoses because there could be serious consequences if a potentially treatable alternative cause is missed.
How the recommendations might affect practice
The recommendations largely support current practice, and they should not have a significant resource impact.
PCR was not included as part of cerebrospinal fluid investigations in the 2010 meningitis guideline, but it has since become standard practice in most hospitals.
Principles guiding antibiotic decisions
Why the committee made the recommendation
Although the recommendations that refer to C-reactive protein (CRP) results make it clear that this measure should be used alongside factors that together help to build the full clinical picture, the 2026 committee wanted to make sure that CRP results alone were not determining antibiotic treatment. They, therefore, agreed to make a recommendation about this.
How the recommendations might affect practice
The recommendation reinforces current best practice.
Infectious disease advice
Why the committee made the recommendation
To help with treatment decisions, the 2012 guideline on early-onset neonatal infection recommended that healthcare professionals with experience in neonatal infection should be available to provide microbiological or paediatric infection disease advice. The 2021 committee decided that this recommendation is also important when making decisions about antibiotic treatment for late-onset infection.
How the recommendation might affect practice
The recommendation reinforces current best practice.
Switching treatment to oral antibiotics for babies with early-onset neonatal infection
Recommendations 1.22.1 to 1.22.6
Why the committee made the recommendations
For babies born from 35+0 weeks' gestation with suspected early-onset bacterial infection who were clinically stable, evidence showed that switching their treatment from intravenous antibiotics to oral antibiotics was associated with reduced hospital stays compared with remaining on intravenous antibiotics because they were able to be treated at home, without increasing serious adverse outcomes. The impact on mortality, adverse events, reinfection, readmission to hospital, completion of antibiotic course, proportion of babies who were exclusively breastfed, sleep quality, and number of healthcare professional visits was uncertain but appeared similar between babies whose treatment was switched to oral antibiotics and those who remained on intravenous antibiotics.
Expert witness testimony about healthcare services taking a similar approach to that outlined in the evidence showed that switching treatment to oral antibiotics reduced hospital stays and that the number of babies readmitted to hospital with infection was low, with none developing late-onset sepsis. Other benefits included reduced exposure to gentamicin, which can have serious side-effects, fewer re-cannulations, and positive experiences reported by parents, carers and healthcare staff.
Based on their clinical knowledge and experience and informed by the evidence, the committee agreed on the eligibility criteria for switching to oral antibiotics to ensure the safety and effectiveness of the approach. They agreed that switching to oral antibiotics is beneficial even when the baby needs to stay in hospital for some other reasons, not related to the infection. This is because it means reduced exposure to gentamicin and fewer re-cannulations.
Amoxicillin is recommended as the first-choice oral antibiotic based on the evidence, expert witness testimony and the committee's experience, although the committee emphasised the importance of taking local bacterial resistance data into account. The type and dosage of oral antibiotic used varied across the published evidence, which were all non-UK studies. However, according to the expert witness testimony, the 3 projects across 9 UK sites trialing the approach of switching from intravenous to oral antibiotics and enabling the baby to go home (oral-switch approach) were already using oral amoxicillin or were about to start using it.
The committee agreed that babies on oral antibiotics at home should remain under the care of the neonatal team until treatment is completed, for safety reasons, but also for continuity of care.
They also agreed that consultants should be involved in any decisions to switch from intravenous to oral antibiotics or for the baby to be treated at home.
Based on the evidence and their experience, the committee identified a series of measures that need to happen before babies on oral antibiotics can go home. They acknowledged that some parents and carers may face challenges in managing oral antibiotic treatment safely at home, and social and family circumstances may influence the shared decision of enabling a baby on oral antibiotics to go home.
A minimum of 2 follow-up consultations were recommended, based on the number of follow-ups reported in the published studies and the committee's opinion. Each of the 9 UK sites trialing the oral-switch approach were providing 1 clinical follow-up, according to the expert witness testimony. The committee decided to adopt a more cautious approach but agreed that the type of consultation (for example, telephone, video conference or face-to-face) should be decided locally.
Given the limited high-quality evidence, particularly from the UK, the committee agreed to make a recommendation for research on switching treatment from intravenous to oral antibiotics for babies with suspected early-onset infection. This could inform future recommendations.
How the recommendations might affect practice
The approach of switching treatment for babies with early-onset neonatal infection from intravenous to oral antibiotics and enabling them to go home is already being adopted in some UK hospitals. The recommendations are likely to increase this further. In turn, this is likely to shorten hospital stays, thereby reducing costs, easing pressure on hospital beds, and improving capacity to care for the sickest babies. This approach could also improve parents' and carers' experiences of the healthcare system and reduce the need to manage the harmful side effects of gentamicin.
For babies on oral antibiotics who need to remain in hospital, while not providing the wider benefits associated with being treated at home this would still reduce care needs connected to the use of intravenous antibiotics, including gentamicin.
It is envisaged that most babies on oral antibiotics will be able to go home.
Neonatal teams will need protocols for following up babies on oral antibiotics at home.
Choice of antibiotics for late-onset neonatal infection
Recommendations 1.23.1 to 1.23.3
Why the committee made the recommendations
There is variation across the country in antibiotic resistance patterns and in which organisms are most likely to cause late-onset neonatal infection. Because of this, local data needs to be used when choosing antibiotics.
Babies in a neonatal unit are likely to have been exposed to different bacteria than babies at home, so the committee made separate recommendations for the 2 groups.
For babies in a neonatal unit, the committee did not believe there was enough evidence to recommend specific antibiotics, and so made a recommendation for research on the optimal antibiotic regimen for treating suspected late-onset infection. However, the evidence available did show that combinations of narrower‑spectrum antibiotics are as effective as broader-spectrum antibiotics. The committee was aware that using broad-spectrum antibiotics in babies is associated with altered gut flora, increased risk of invasive fungal infection and the development of antibiotic resistance, and so a combination of narrow spectrum antibiotics was recommended as first-line treatment.
For babies who have been admitted from home, there was also limited evidence on which antibiotics to use. NICE's guideline on suspected sepsis in under 16s recommends treating community-acquired sepsis with ceftriaxone or cefotaxime depending on gestational age. The committee agreed that these antibiotics would be appropriate for late-onset neonatal infection in babies who have been admitted from home, and none of the evidence for this group contradicted it.
How the recommendations might affect practice
These recommendations will help to reduce the use of broad-spectrum antibiotics as first-line treatment for babies in neonatal units, which may help reduce antibiotic resistance. However, use of narrow-spectrum antibiotics is already standard practice in many units, and the costs of antibiotics are low, so there is expected to be very little impact on resource use, especially as most of the affected babies are already receiving intensive care and monitoring.
The recommendation for babies admitted from home may not have a substantial impact on practice, as it refers to an existing recommendation in the NICE guideline on suspected sepsis in under 16s.
Decisions 48 hours after starting antibiotics for late-onset neonatal infection
Why the committee made the recommendation
There was no evidence on duration of antibiotic treatment for late-onset infection. However, the 2012 guideline on early-onset neonatal infection made recommendations on decisions 36 hours after starting antibiotic treatment, and the committee adapted these so that they were applicable to late-onset infection. The duration of initial treatment is recommended to be 48 hours rather than 36 hours as recommended for early-onset infection. This is thought to reflect the different bacteria that cause late-onset infection, which grow more slowly and have a lower load in the bloodstream. This means that it can take longer for a blood culture to become positive for late-onset than early-onset infection and so treatment needs to continue for longer until a negative blood culture result can be confirmed.
How the recommendation might affect practice
The recommendation on decisions 48 hours after starting treatment is consistent with current practice.
Duration of antibiotics for late-onset neonatal infection
Recommendations 1.25.1 to 1.25.4
Why the committee made the recommendations
No evidence on treatment duration was identified, and so the committee made recommendations based on their knowledge and experience. The committee recommended a treatment of 7 days for babies with a positive blood culture, consistent with the 2012 guideline on early-onset neonatal infection.
The committee recommended that a shorter treatment duration should be used when no pathogen is identified (the blood culture is negative) or the pathogen is a common commensal. In these situations, the committee noted that infection was likely to be less severe and could be safely treated with a shorter treatment duration, which would have the advantage of reducing exposure to antibiotics, which is consistent with the principles of good antibiotic stewardship.
The committee also specified situations when a longer treatment duration should be used, such as when there is intra-abdominal co-pathology, necrotising enterocolitis, osteomyelitis or infection of a central venous catheter. There was no evidence for the specific situations where longer treatment would be required, but the committee based their decisions on their knowledge and experience.
How the recommendations might affect practice
The recommendations on duration of treatment are consistent with current practice.
Antifungals to prevent fungal infection during antibiotic treatment for late-onset neonatal infection
Why the committee made the recommendation
Evidence from randomised controlled trials showed that both nystatin and fluconazole can reduce the risk of a baby developing an invasive fungal infection in comparison to placebo or no treatment. Evidence marginally favoured the use of nystatin over fluconazole for reducing the risk of fungal infection and based on the knowledge and experience of the committee, nystatin is better tolerated and there is a lower risk of fungi developing resistance to this antifungal than fluconazole. Economic evidence showed that nystatin was also likely to be the most cost-effective option, and so the committee recommended oral nystatin for antifungal prophylaxis when a baby is being given antibiotics for late-onset neonatal infection. The recommendation for antifungal prophylaxis was limited to babies below 1,500 g or 30 weeks' gestational age because the evidence was from babies in these population groups.
Although oral nystatin was the committee's first choice for antifungal prophylaxis, oral administration of antifungals may not be possible for all babies, particularly those who are very premature. The committee therefore specified that the use of intravenous fluconazole is appropriate when oral administration is not possible.
The committee made a recommendation for research on the optimal regimen for giving antifungal prophylaxis when treating a baby with antibiotics for late-onset infection, because evidence was not available to support specific recommendations on the duration and dose of antifungal treatment that should be used.
How the recommendation might affect practice
This recommendation may increase the number of babies who are given nystatin as antifungal prophylaxis when they are prescribed antibiotics for late-onset infection. This should decrease the number of babies who need to be treated for fungal infection which, although rare, can have serious consequences. Economic modelling showed that giving antifungal prophylaxis is likely to be cost saving because of a reduction in costs associated with treating invasive fungal infections and their consequences.
Antibiotic treatment for early- and late-onset meningitis (babies in neonatal units)
Recommendations 1.27.1 to 1.27.6
Why the committee amended the recommendations
These recommendations were carried forward from the 2012 guideline on early-onset neonatal infection, but were expanded to cover both early-onset and late-onset neonatal meningitis for babies in neonatal units based on the knowledge and experience of the committee. Evidence relating to these recommendations was not reviewed for late-onset meningitis, but the committee agreed that the recommendations that were made in 2012 for early-onset infection would also apply to late-onset meningitis for babies treated in neonatal units.
How the recommendations might affect practice
The recommendations reinforce current best practice.
Fluid restriction for confirmed bacterial meningitis
Recommendations 1.28.1 and 1.28.2
Why the committee made the recommendations
For babies over 28 days, children and young people, there was a small amount of evidence comparing fluid restriction with routine maintenance fluids. This evidence showed that fluid restriction reduces pulmonary and facial oedema. However, it also increases rates of neurological impairment and epilepsy. There was no evidence in newborn babies aged 28 days or under, or in adults. However, the committee extended the recommendations to cover these groups because they agreed the risks were likely to be the same, based on their knowledge and experience.
The committee was particularly concerned about the increased rate of neurological impairment, as this could be the most important clinical outcome. Based on the evidence and their knowledge and experience, the committee agreed not to recommend routine fluid restriction for bacterial meningitis. They specified 'routine' because they did not want to stop healthcare professionals from restricting fluids in babies with fluid overload.
There are potential complications to providing fluids intravenously, and in the committee's experience babies with bacterial meningitis can often tolerate oral or enteral fluids. Because of this the committee recommended providing fluids orally or by enteral tube when possible.
How the recommendations might affect practice
Fluid restriction is not part of routine practice, although it may be used for people with fluid overload.
Assessing for immunodeficiency and recurrence risk in babies with bacterial meningitis
Recommendations 1.29.1 to 1.29.3
Why the committee made the recommendations
The committee had concerns about the reliability of the evidence, because the sample sizes were not large enough to detect rare events and because people with known immunodeficiency will often receive interventions to prevent recurrent infections. Because of this, the committee used their knowledge and expertise to make recommendations.
The committee agreed that primary immunodeficiency is present in 8 to 26% of children with invasive pneumococcal disease.
The committee agreed that referral to specialists was needed for babies with pneumococcal meningitis, because this disease may indicate a lack of immune response to pneumococcal vaccination and may be associated with primary immune deficiencies.
Some anatomical factors increase the risk of bacterial meningitis. The committee agreed that babies should be checked for these factors (including signs of a sinus tract), to assess whether they may need intervention to prevent future episodes.
How the recommendations might affect practice
The recommendations are in line with current practice.
Preparing for discharge for babies who have had bacterial meningitis
Recommendations 1.31.1 to 1.31.4
Why the committee made the recommendations
Evidence showed that meningitis can result in a range of long-term complications, such as:
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learning disability, which can lead to speech and language problems in babies, as well as poor educational attainment or the need for special educational assistance
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long-term behavioural problems and problems with adjustment
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psychological distress
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hearing problems, including acute deafness.
Most of the evidence concerned long-term complications for babies over 28 days, children, young people and young adults. However, the committee agreed that it was reasonable to extrapolate much of this evidence to newborn babies, because meningitis can have similar impacts on people regardless of age.
Based on this evidence, the committee agreed that people with bacterial meningitis should not be discharged from hospital until follow-up needs have been identified and planned for, and until certain assessments have been planned or completed. The committee did recognise that certain tests, like an audiological assessment, might not be possible until after discharge (although testing before discharge would be preferable).
The evidence for epilepsy as a long-term complication was mixed. For example, there was evidence of an increase in children who have had meningitis being admitted as inpatients because of epilepsy, but no evidence of increased use of outpatient epilepsy services in the same population. The committee was also concerned about unnecessary long-term use of anti-epileptic drugs. They recommended a 3-month review to check whether the seizures were a short-term effect of the illness.
The evidence on long-term complications after bacterial meningitis in newborn babies was limited to a single, small study. The committee agreed that quantifying the long-term complications of bacterial meningitis is important, to allow follow-up to be arranged for those at risk and to help with prioritising treatment and prevention strategies. To address this, the committee made a recommendation for research on the long-term outcomes after bacterial meningitis in infancy.
How the recommendations might affect practice
It is routine practice to identify possible follow-up needs before discharge and to make referrals when needed.
Psychosocial support for family members and carers of babies who have had bacterial meningitis
Why the committee made the recommendation
Referral for psychosocial support is recommended because of the potential psychological impact of meningitis on family members and carers. It may need to be arranged after discharge because the impact may not be apparent immediately.
How the recommendation might affect practice
It is routine practice to make referrals and plan for care after discharge.
Care after hospital discharge for babies who have had bacterial meningitis
Recommendations 1.33.1 to 1.33.7
Why the committee made the recommendations
The committee agreed areas to cover in the post-discharge review based on the evidence of the long-term complications associated with meningitis.
The review should happen at 4 to 6 weeks after discharge so that short-term effects of the illness can be ruled out and long-term issues can be identified early enough to make prompt referrals. The results of hearing tests may not be available at this point (for example, if illness interferes with the timing of the test), but the overall review should not be delayed if this is the case.
The evidence showed particular long-term complications for babies, children and young people. The committee used their own knowledge and experience to make recommendations on further tests and reviews for babies. These tests and reviews are important for identifying late-onset complications and developmental issues as children and young people grow up.
The tests and reviews recommended will involve staff working in multiple services, across health and education. The committee made a recommendation on coordinating follow-up, to avoid situations where professionals assume other services are responsible and people do not receive proper care as a result.
The evidence suggested that meningitis can increase the risk of poor educational outcomes, that the impact of long-term complications may not always be apparent, and that children and younger people who are seen to be underachieving could be achieving more if they had more specific support. This guideline does not cover education settings, so the committee advised parents and carers to discuss educational complications with their child or young person's school.
How the recommendations might affect practice
It is routine practice to review people who have had meningitis for long-term complications after hospital discharge.
Risk factors for recurrent bacterial meningitis
Why the committee made the recommendation
Evidence showed that some anatomical factors increased the risk of recurrent bacterial meningitis (such as a cerebrospinal fluid leak). For most immunological factors, there was no evidence that met the review criteria.
The committee had concerns about the reliability of the anatomical and immunological evidence, because the studies only looked at a very small number of people for some risk factors and for recurrent bacterial meningitis in general. Because of this, the committee made recommendations about the risk factors they believed to be most important, based on their knowledge and experience.
How the recommendation might affect practice
The recommendation is largely in line with current practice. Healthcare professionals may have to change some of the risk factors they look for, but there should be no resource impact for services.
Managing recurrent bacterial meningitis
Recommendations 1.34.2 to 1.34.6
Why the committee made the recommendations
There was no evidence, so the committee made recommendations based on their knowledge and experience. They recommended a specialist review to decide which investigations, treatments and immunisations were needed to help prevent further recurrence.
The committee made recommendations on immunisation, medicine history, and sinus tract examination, in line with the recommendations on assessing for immunodeficiency and recurrence risk (see the explanation of the recommendations on assessing for immunodeficiency and recurrence risk).
The committee also highlighted the possibility of other rare causes of recurrent meningitis.
How the recommendations might affect practice
Specialist review and prophylactic antibiotics are part of routine current practice for babies with recurrent bacterial meningitis.
Planning for care after discharge
Recommendations 1.38.1 to 1.38.4
Why the committee made the recommendations
There was evidence on the views and experiences of families and carers of people who have had meningitis. The committee built on this with their own expertise. They recommended coordination with other professionals and services because this will ensure that follow-up care and support meet the person's needs, and will potentially reduce the impact of long-term complications.
How the recommendations might affect practice
It is routine practice to make referrals and plan for care after discharge, and to inform GPs and other key professionals of any follow up needs.