Neonatal Drug Formulary Santosh T Soans, Murali Keshava Sarpangala
INDEX
A
Agents that can safely be administered in therapeutic doses to glucose-6-phosphate dehydro- genase deficient patients 41
Agents to be avoided in glucose-6- phosphate dehydrogenase deficient patients 41
Amniotic fluid analysis 78
Analyses of cerebrospinal fluid 76
Analyses of feces 77
Antenatal drugs for surfactant production 62
Antibiotic guidelines in neonatal infection 14
Antihypertensive agents for the newborn 58
Antimicrobial agents 1
dosages and intervals of administra- tion 1
organisms generally susceptible to cephalosporins 13
organisms generally susceptible to penicillins 11
Antimicrobials requiring adjustment in renal failure 47
Apgar score 81
Approach to a bleeding neonate 73
hemoglobin F mean (SD)% total Hb 73
hemoglobin Nadir in babies in the first year of life 73
Kleihauer-Betke test 73
mean hematologic values in preterm and term newborns 73
Approach to indirect hyperbilirubi- naemia in healthy term infants without hemolysis 87
Arterial blood gas 67
Average daily nutritional requirements 52
B
Bed side evaluation of apnea 62
Behavioural pain score for full-term infants undergoing interven- tions or postoperative care 66
Bilirubin (total) 68
Blood pressure for weight percentiles 93
Blood volume 85
elective blood transfusion 85
electrolyte requirements in newborn 86
estimated blood volumes 85
factors affecting water loss (IWL) in preterm infants 85
fluid requirement changes in different conditions 86
IV fluid requirement of LBW neonates 85
Bone marrow differential counts; mean percent changes with age (range) 71
C
Calcium total 68
Causes of apnea 62
Clinical correlation of jaundice in skin and levels of serum bilirubin 87
Clinical interventions in neonatal apnea 62
Coagulation factor assays 71
reference values for coagulation inhibitors in healthy prema- ture infants during the first month of life 72
reference values for coagulation tests in healthy premature infants (30 to 36 weeks of gestation) during the first month of life 71
reference values for coagulation tests in the healthy full-term infant during the first month of life 72
reference values for the inhibition of coagulation in the healthy full- term infant during the first month of life 72
Cofactor/limiting amino acid therapy 54
Commercial formulas and foods 55
composition of human milk, standard infant formulas, and some specialized formulas 55
formulas for metabolic disorders 55
formulas free of lactose and or cow's milk protein and special milk based (casien-hydrolysate) formulas 56
formulas with altered fat, protein, and carbohydrates 56
Commercial vitamin preparations 32
Commonly used intravenous solutions composition per litre 86
Comparison of thrombolytic agents 60
Composition of various milks 52
Concentration and duration of few infusions 40
Congestive heart failure 51
Creatinine 68
Creatinine phosphokinase 69
Crib (clinical risk index for babies) score 83
D
Determining endotracheal tube size 80
Dose of intravenous indomethacin in premature infants with patent ductus arteriosus 63
Drug formulary 18
Drug loss during exchange transfusion 40
Drugs in breastfeeding 42
Drugs requiring no adjustment 50
Drugs that cause significant displace- ment of bilirubin from albumin in vitro 51
Drugs to be used with special precau- tion in breastfeeding women or drugs contraindicated 42
Drugs used in resuscitation 33
E
Effect of change in ventilatory para- meters on the blood gas 64
Evaluation of transudate vs exudates 79
Examination of sweat 79
Exchange transfusion table 88
early indications for exchange blood transfusion in infants with Rh- hemolytic disease of the newborn 88
F
Fetal antiarrhythmic agents 60
First line antibiotics 16
G
Gamma-glutamyltransferase 69
Glasgow coma scale 82
ABG score 82
best motor response (total points 6) 82
best verbal response (total points 5) 82
Downe's score 82
eye opening (total points 4) 82
Silverman-Anderson retraction score 82
Guidelines for the initial ventilatory settings disease-wise 65
Guidelines for the modes of providing fluids and feeding 53
H
Health indicators of India (UNICEF 2000) 79
I
Indices to differentiate between pre- renal and intrinsic renal failure and SIADH 77
Infant and child mortality rates (NFHS survey) 79
Initial dosing of enoxaprin, age- dependent 59
Initial ventilator settings 64
Inotropic and vasoactive agents commonly used in shock 35
Intrapartum monitoring fetus 80
interpretation 81
Intubation sedation guidelines 34
Iron supplementation guidelines in the premature infant 54
L
Leukocyte count and differential count during the first two weeks of life 74
Local site-directed thrombolytic therapy 59
M
Metabolic acidosis 68
Monitoring and dosage adjustment of enoxaparin based on anti- factor Xa level measured 4 hours after dose of enoxaparin 60
N
Neonatal infant pain scale 66
Neonatal pulmonary physiology by disease state 65
Neonatal ventilation 64
Neutrophilia values predictive of neonatal bacterial infection 74
Non-antimicrobials requiring adjust- ment in renal failure 49
Normal blood chemistry values, term neonates 75
normal blood chemistry values, low birth weight neonates, first day 75
Normal blood gas values in term newborns 80
Normal electrocardiographic values 60
Normal longitudinal blood pressure in full-term infants 58
Normal values of blood fractions 70
Nutritional needs of low birth weight infants 52
O
Oral dietary supplements available for use in infants 54
Osmolality of fluid 86
Oxygen delivery devices 63
Oxygen dissociation curve 94
P
Passage of antibiotics across the placenta 45
Pathological states 46
gastrointestinal diseases 46
kidney disease 47
liver disease 47
Peak and trough levels of antibacterial agents 39
Pharmacokinetics 46
Pharmacotherapy for neonatal apnea 62
Phototherapy guidelines for neonatal hyperbilirubinemia 92
Phototherapy table 88
Physiologic basic types of apnea 61
Primitive reflexes 84
Protamine dosage to reverse heparin therapy 59
Protein electrophoresis 70
Prothrombin time 75
R
Recommended daily allowances of vitamins and minerals 53
Reference laboratory values 67
Risk estimation of icterus 91
S
Safe medicine 39
Sarnat and sarnat stages of hypoxic- ischemic encephalopathy 63
Score for neonatal acute physiology (snap) 83
Septic risk scoring 15
Serum iron and iron-binding capacity 75
Significance of blood culture isolates 14
Some important metabolic conditions 55
Special nutrition 52
Specific antibiotic therapy in early- onset neonatal septicemia 15
Specific antibiotic therapy in late-onset neonatal septicemia 15
Specific therapeutics 58
Standard IV infusion routinely prepared 36
Standard TPN regimen 57
Suggested antibiotic regiments for sepsis and meningitis 15
Suggested intakes of parenteral vitamins in infants 57
Suggested maximum indirect serum bilirubin concentrations in preterm infants 87
aliquots used in exchange transfusion 87
calculated using the formula 2 × blood volume + 50 ml 87
exchange transfusion 87
Systemic thrombolytic therapy 59
T
Teratogenicity 44
Therapeutic range of various drugs 39
Thermoneutral environment 88
Thrombin time 75
Thrombolytic therapy 59
Thyroid disease 51
Time table for elective surgical repair 58
Transport 88
medications used on transport 89
supplies used by transport teams 89
transport team equipment 88
Treatment guideline in icterus 95
Tube feeding guidelines 53
U
Urinary biochemical values 76
Urine metabolic screening 84
V
Venous platelet counts in normal low birth weight infants, range (X 10,000) 74
Ventilator manipulations to increase oxygenation 64
Ventilator manipulations to increase ventilation and decrease PaCO2 65
Ventilatory calculations 65
Viral infection therapy 17
×
Chapter Notes

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Antimicrobial AgentsCHAPTER 1

 
 
Dosages (mg/kg/day) and Intervals of Administration
Body Weight <2000g
Body Weight >2000g
Antibiotics
Routes of Administration
Age 0–7 days
>7 days
Age 0–7 days
>7 days
Comments
Acyclovir (zovirax, ocuvir) 250 mg, 500 mg vial
IV
10 mg/kg q8h for 10-14 days
Dilution to 5 mg/ml, infuse 8h over 1 hour
5 mg/kg q8h
Prophylactic dose:
Adverse reactions noted: Transient renal dysfunction and thrombophlebitis. Increase dosing interval q24 h when renal functions < 25% of normal. Oral absorption not tested in neonates.
Amikacin (mikacin)
(50 mg/ml 2 ml vial)
IM, IV
<28 wk
28-34 wk
>34 wk
7.5 mg/kg q24h
7.5 mg/kg q18h
7.5 mg/kg q12h
IV infusion over 30 minutes
<28 wk
28-34 wk
>34 wk
7.5 mg/kg q18h
7.5 mg/kg q12h
7.5 mg/kg q8h
Ototoxicity, nephrotoxicity, neuromuscular blockade, BM suppression, eosinophilia and tremor. Synergestic action with diuretics. Therapeutic range: 20-30 mg/L (peak) and <8 mg/L (trough) CSF penetration is poor, even in meningitis. Preferred in serious infections of gram-negative bacilli. Susceptible pathogens include Pseudomonas, E. coli, Proteus, Klebsiella, Serratia, Staphylococcus. It exerts bactericidal action by inhibiting protein synthesis.
Amoxicillin (mox)
(250 mg, 500 ml vials)
PO IV, IM
50 mg/kg
q12 h
50 mg/kg
q8h
Increase dose to 100 mg/kg in suspected meningitis
50 mg/kg
q12h
50 mg/kg
q8h
SE: rash, diarrhoea. It exerts bactericidal by virtue of its ability to inhibit synthesis of the bacterial cell wall. Susceptible pathogens include α and β–hemolytic streptococci, strep pneumoniae, strep faecalis, Bacillus anthrasis, Clostridium spp except C. difficile, some non-Betalactamase staphylococci, B. Pertusis, Haemophillus, E. coli, Proteus, Salmonella, Shigella, Treponema, Pseudomonas.
Amoxyclav
(augmentin)
PO, IV
———
40 mg/kg/day q8h
(Amoxycillin 6.7 mg/kg q8h
———
40 mg/kg/day q8h
(Amoxycillin 13.3 mg/kg q8h
Inhibits production of β–lactamases. Many β–lactamase producing strains
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Clavulinic acid 1.7 mg/kg q8h)
Clavulinic acid 3.3 mg/kg q8h)
of staph aureus and coagulase negative Staphylococcus species are made sensitive.
Amphotericin
B (fungizone)
Polyene antifungal (50 mg/vial)
IV
0.5-1.0 mg/kg/O.D with maximum of 1.0 mg/kg/day for 4-6 weeks (total dose of 25-40mg)
NOTE:
  1. Dilute in D5W or D10W only.
  2. Minimum dilution is 0.1mg/ml.
  3. Infuse over 2-6 hours.
  4. Start with 0.25 mg/kg/day increase dose by 0.25 mg/kg/day.
  5. Reconstituted preparations should be protected from light.
  6. The first 0.1 mg of the first dose will be considered as test dose.
  7. Total dose should not exceed 20-30mg/kg
Adverse reactions: hypotension, thrombophlebitis, renal dysfunction (hypokalemia, azotemia, RTA, hematologic (anemia, thrombocytopenia, granulocytopenia) Monitor closely hematologic and renal status (CBC, platelet count, serum BUN, creatinine, electrolytes). Reduce dosage or interrupt therapy or alternate day therapy when renal function falls to <20% of normal. Adverse effects appear to be less common in neonates. Fever, chills, nausea and vomiting are common side effects, may premedicate with acetaminophen and diphenhydramine 30min before and 4 hrs after infusion.
Ampicillin (roscillin)
IV, IM
Meningitis Other disease PO
50 mg/kg q12h
25 mg/kg q12h
50 mg/kg q8h
25 mg/kg q8h
50 mg/kg q8h
25 mg/kg q8h
50 mg/kg q6h
25 mg/kg q6h⁡
62.5 mg/kg/dose q6h
At high doses SE are same as penicillin. May cause interstitial nephritis, hemolytic anaemia and pseudo-membranous colitis. More active than penicillin against Listeria Monocytogenes, E. coli, Proteus, Salmonella. CSF penetration is slightly better than penicillin G.
Azlocillin
IV
50 mg/kg q12h
50 mg/kg q12h
100 mg/kg q12h
100 mg/kg q8h
Must not be mixed in same syringe or infusion with aminoglycosides.
Aztreonam (Azenam)
IV, IM
30 mg/kg q12h
30 mg/kg q8h
30 mg/kg q8h
30 mg/kg q6h
β–lactum antibiotic, active against gram-negative enteric bacilli including pseudomonas aeruginosa. SE: Thrombophlebitis, eosinophilia; leukopenia, neutropenia, thrombocytopenia, increase liver enzymes, hypotension, seizures. If creatinine clearance is between 10–30 ml/min, the dose should be halved after giving an initial loading dose. In severe reveal failure or on dialysis should recieve the standard loading dose, followed by ¼ of the loading dose at standard dose interval. It interacts with penicillinbinding
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proteins of susceptible microorganisms and induces the formation of long filaments bacterial structures lending to lysis of the bacterial cell.
Carbenicillin
IV, IM
75 mg/kg
q12h
75 mg/kg
q8h
75 mg/kg
q8h
75 mg/kg
q6h
It has additive inhibition of platelet function and hence may increase the risk of haemorrhage. May produce hypokalemia. Do not mix with genta.
Cefaclor (keflor)
(125 mg/ 5ml)
PO
20 mg/kg q12h
Active against haemophillus influenzae including strains producing β– lactamases.
Cefazolin (Reflin)
(125 mg, 250 mg vials)
IV, IM
20 mg/kg q12h
20 mg/kg q12h
20 mg/kg q12h
20 mg/kg q8h
Caution with penicillin allergy or renal impairment. Leukopenia, thrombocytopenia, increase liver enzymes, false +ve urinary reducing substances. Active against gram-positive including staphylococcus aureus (even penicillinase producing organisms), Group A beta-hemolytic streptococci, Streptococcus pneumoniae, gram-negative including E. coli Proteus, Klebsiella, H. influenzae, Enterobacter.
Cefotaxime (traxim) (500 mg vial)
IV, IM
50 mg/kg q12h
50 mg/kg q8h
50 mg/kg q12h
50 mg/kg q8h
Good CNS penetration. Rash. Thrombocytopenia, leucopenia. Active against staphylococci,H. influenzae, Salmonella, Shigella, Serratia, Spirochetes, Citrobacter, Neisseria, Proteus and Pseudomonas. In renal impairment with creatinine clearance of 5ml/min or less, dose is reduced to ½.
Cefoxitin
IV
15 mg/kg q8h
30 mg/kg q6h
15 mg/kg q8h
30 mg/kg q6h
Thrombophlebitis. Activity against bacteroides fragilis and indole positive proteus.
Ceftazidime (fortum, Tazid) (250 mg vial)
IV, IM
Meningitis Other disease
50 mg/kg q12h
30 mg/kg q12h
50 mg/kg q8h
30 mg/kg q8h
50 mg/kg q8h
30 mg/kg q12h
50 mg/kg q8h
30 mg/kg q8h
Rash, false positive Coomb's test. Active against pseudomonas. It has extended spectrum of activity against gram-negative bacteria especially pseudomonas. Highly stable to betalactamases. In renal insufficiency dose is modified according to creatinine clearance. Urticaria, neutropenia, thrombocytopenia, pseudomembranous colitis, increased liver enzymes.
Give IV infusion over 30 minutes
Ceftriaxone (monocef)
IV, IM
Meningitis
100 OD
100 OD
100 OD
100 OD
Reversible cholelithiasis sludging in GB and jaundice.
4
(250 mg vial)
Loading
Maintenance Other disease
50 mg/kg q12h
50 OD
50 mg/kg q12h
50 OD
50 mg/kg q12h
50 OD
50 mg/kg q12h
50 mg/kg OD
Caution in neonates with hyperbilirubinemia. Skin rash, pseudomembranous colitis. Potentiates nephrotoxicity along with aminoglycosides and frusemide. Chloramphenicol decreases its efficacy. Pseudomonas shows variable susceptibility. Stable against beta-lactamases.
Cefuroxime (altacef, forcef)
(250 mg vial)
IV, IM
30 mg/kg q12h
30 mg/kg q8h
30 mg/kg q12h
30 mg/kg q8h
Not recommended for meningitis. Pseudo-membranous colitis, transient increase in urea and creatinine, rash. Active against staphylococci, streptococci, Neisseriae, H. influenzae and gram-negative organisms including E. coli, Klebsiella, Proteus. Not active against Pseudomonas or streptococcus faecalis. Specially active against betalactamase producing strains of H. influenzae and N. Gonorrhoeae.
For IV infusion, dilute reconstituted dose with NS or DS and infuse over 30 minutes.
Cephalothin
IV, IM
20 mg/kg q12h
20 mg/kg q8h
20 mg/kg q12h
20 mg/kg q8h
Limited experience in neonates.
Chloramphenicol (enteromycetin)
(250 mg, 500 mg vial)
(as sodium succinate)
IV, PO
25 mg/kg once daily
25 mg/kg once daily
25 mg/kg once daily
50 mg/kg q12
Dose related or ideosyncratic BM suppression, “Gray baby” syndrome, phenobarbitone, rifampicin decreases chloramphenicol levels. Phenytoin increases chloramphenicol levels. Therapeutic levels = 15-25mg/L for meningitis; 10-20mg/L for other infection. Active against most gram-positive and gramnegative bacteria. Active against Neisseriae, Streptococcus pneumoniae, H. influenzae, staphylococci, streptococci, Salmonella, Shigella, Anaerobes, Ricketssiae and Brucella. Not effective against Pseudomonas.
Give IV bolus with NS or DS
Ciprofloxacin (cifran, ciplox) (2 mg/ml, 50 ml/ 100 ml for IV infusion)
PO
IV
7.5 mg/kg q12h
5 mg/kg q12h
7.5 mg/kg q12h
5 mg/kg q12h
7.5 mg/kg q12h
5 mg/kg q12h
7.5 mg/kg q12h
5 mg/kg q12h
Damage to cartilage is observed in experimental animals. Has stood the test of time and no such thing documented in humans? Active against Pseudomonas. When given orally requires acidic media for absorption. Concurrent administration of sucralfate, magnesiumaluminium antacids and ranitidine decreases its absorption. Theophylline concentrations are markedly elevated when co-administered with ciprofloxacin. Potentials oral anticoagulants.
Infusion given over 30-60 minutes
5
Clindamycin (clincin)
(150 mg/ml 2 ml vial)
IV, IM
5 mg/kg q12h
5 mg/kg q8h
5 mg/kg q8h
5 mg/kg q6h
Not indicated in meningitis, Diarrhoea, rash, Stevens-Johnson syndrome. Pseudomembranous colitis, Thrombo cytopenia, Granulocytopenia. Active against Staphylococci, Streptococci, Bacteroides fragilis and some anaerobes.
Dilute to 6 mg in 1 ml with NS and D5 infuse slowly over 10-30 minutes.
Clotrimazole Topical (candid)
Apply to skin BID x 4-8 wks
Thrush: Dissolve slowly one troche in the mouth 5times/day x 14 days.
Erythema, blistering, urticaria where applied.
Cloxacillin (klox)
(250 mg vial)
IV
25 mg/kg q12h
25 mg/kg q8h
25 mg/kg q8h
25 mg/kg q6h
Double dose for meningitis. Active against Staphylococcus aureus, coagulase negative staphylococci. Poor activity against Treponema pallidum and anaerobes. Its potency is lost in solution with erythromycin, gentamycin, kanamycin, colistin sulfate, chlorpromazine, vitamin C and polymyxin B sulfate. Chloramphenicol antagonizes its bactericidal activity.
Dose may be increased to 100 mg/kg in severe infections. Do not mix with aminolycosides.
Colistin sulphate
Polymixin antimicrobial
PO, IM
40 mg/kg q6h
40 mg/kg q6h
40 mg/kg q6h
40 mg/kg q6h
Active against gram-negative anaerobes including most enterobacteria except proteus, providential and serratia. Activity is also seen against Pseudomonas, Legionella, H. influenzae, Acinetobacter, V. cholera, Salmonella, Shigella and pasteurella.
Give deep IM
Co-trimoxazole (bactrim, septran) (480 mg in 5 ml anpaele 240 mg/ 5 ml suspension
IV
PO
Minor infections: Prophylaxis (UTI): Serious Infections and Pneumocystitis carinii pneumonia
Pneumocystitis carinii prophylaxis
4 mg TMP + 24 mg SMX/kg q12h
4 mg TMP + 20 mg SMX/kg once daily
10 mg TMP+ 50 mg SMX/kg q12h
480 mg/m2 q12h EOD (3 days/wk)
For use with caution in infants <1 month; (TMP) to (SMX) ratio is 1 to 5. Can displace bilirubin bound to albumin. Both inhibit folic acid synthesis by the pathogen but at different stages which results in some potentiation of action. Active against staphylococci, enterococci, E. coli, Proteus. Diffuses well into CSF and brain. Steven-Johnson syndrome, agranulocytosis, thrombocytopenia.
Erythromycin (althrocin) (100 mg/ml drops)
PO,
IV
10 mg/kg q12h
10 mg/kg q8h
10 mg/kg q12h
15 mg/kg q8h
May increase serum theophyllin level. Cyclosporine, digoxin, CBZ MPS increases serum levels. Caution: liver disease, with terfenadine cisapride. Estolate may cause cholestasis. Active against gram-positive organisms, including penicillinase producing staphylococci, diphtheria, mycoplasma, urea plasmas, chlamydia, bordetella pertusis and most gram-nega-
IV infusion is given after diluting in 5% dextrose (not available in indian market)
6
tive organisms. It is used as an alternative to penicillin, in those allergic to penicillin. Topical preparations are also available. Antibacterial activity potentiated by acetazolamide and sodium bicarbonate.
Flucloxacillin 50 mg/ml suspension
IV,
PO
50 mg/kg q12h
25 mg/kg q12h
50 mg/kg q8h
25 mg/kg q8h
25-50 mg/kg q6h
Double dose for meningitis. Active against Staphylococcus aureus,coagulase negative staphylococci. Poor activity against Treponema pallidumand anaerobes.
Fluconazole (zocon) (2 mg/ml) 25 ml bottle
IV
PO
< 14 days
14-28 days
>28 days
6-12 mg/kg every 72 hr
6-12 mg/kg every 48 hr
6-12 mg/kg every 24 hr
Systemic candidiasis and cryptococcal infection. 3 mg/kl for mucosal candidiasis. Reduce dose in renal impairement. In over 10-30 min.
Flucytosine (5 FC)(10 mg/ml 250 ml bottle)
IV PO
25 mg/kg q6h
Theurapeutic level = 25-100mg/L
25-50 mg/kg q6h
Adverse reactions noted: enterocolitis, nausea/vomiting diarrhoea, hepatotoxicity, bone marrow suppression. Monitor closely hematologic, renal and liver function status. Increase dosing interval q12h when renal function 50% of normal and to q24h when renal function <10% of normal.
IV infusion over 20-40 min through filter
Fucidic acid
IV, PO
5 mg/kg q6h
5 mg/kg q6h
5 mg/kg q6h
5 mg/kg q6h
For IV use dissolve powder in buffer provided and infuse dose over 6 hours.
Ganciclovir 500 mg vial
IV
Induction 5 mg/kg q12h or 2-5 mg/kg q8h for 14-21 days.
Maintenance therapy: 5 mg/kg OD for 5 days/wk.
Limited experience in neonates. Reduce dose in renal failure. Neutropenia, thrombocytopenia, retinal detachment. IM and SC administration are contraindicated because of high pH (II).
Reconstitute with 10 ml water (50 mg/ml)
Infuse over 1 hour. Irritant, handle carefully.
Gentamycin (garamycin) (10 mg/ml, 40 mg/ml, 2 ml vial)
IV, IM
<28 wk
28-34 wk
> 34 wk
2.5 mg/kg q24h
2.5 mg/kg q18h
2.5 mg/kg q12h
<28 wk
28-34 wk
> 34 wk
2.5 mg/kg q18h
2.5 mg/kg q12h
2.5 mg/kg q8h
Proximal tubule dysfunction, ototoxicity.
Therapeutic level=6–10mg/L (peak) <2mg/L (trough). Eliminated more quickly in patients with cystic fibrosis, multiple sclerosis, burns, neutropenic patients. Active against gramnegative organisms, weak activity against staphylococci and streptococci. Babies on dialysis an 8 hr dialysis reduces serum levels of gentamycin by 50%. At the end of each session give 2mg/kg. Cephalosporin, hydrocortisone and indomethacin potentiate nephrotoxicity. Potentiates neuromuscular blocking agents. Frusemide potentiates its toxicity.
7
Imipenem beta-lactam antibiotic (500 mg with 500 mg cilastatin)
IM IV
20 mg/kg q6-8h over 30-60mins.
20 mg/kg q6-8h
20 mg/kg q6-8h
20 mg/kg q6-8h
Pruritis, urticaria, seizures, hypotension, increased lever enzymes, blood dyscrasias. IM formation cannot be given IV. Each gram contains 3.2 mEq sodium.
Isoniazid (Isonex) 50 mg tab
PO
5 mg/kg q12-24h
5 mg/kg q12-24h
5 mg/kg q12-24h
5 mg/kg q12-24h
Pyridoxine supplement should be given (5 mg).
Kanamycin (kancin)
IV, IM
5 mg/kg q12h
5 mg/kg q8h
10 mg/kg q12h
10 mg/kg q8h
Retinal toxicity and ototoxicity poorly absorbed orally. Give over 30min IV. Reduce dosage frequency with renal impairment. Active against Staphylococcus aureus (including penicillinase producing organisms), Staphylococcus epidermidis, H. influenzae, E. coli, Klebsiella, Serratia and Proteus.
Meropenem (meronem) carbapenem beta-lactam (500 mg vial)
IV
Sepsis: 20 mg/kg q12h
Meningitis: 40 mg/kg q8h
20 mg/kg q12hr
20 mg/kg q8hr
Limited experience in neonates. Dose should be reduced in patients with creatinine clearance less than 51ml/min. 26-50 ml/min give recommended dose q12h. 10-25ml/min give ½ the recommended dose q12h. <10 ml/min give ½ the recommended dose q24h monitor LFT, blood counts.
Slow IV injection
Metronidazole (metrogyl) (5 mg/ml, 20 ml ampoule, 100 ml container)
IV
Loading 15mg/kg stat, maintenance 24 hr later as the following:
Neutropenia. Candidiasis may worsen. Potentiates anti-coagulants. Use with caution in patients with liver or renal disease (GFR <10ml/min). Active against anaerobes (useful in necrotising enterocolitis) and entamoeba histolytica. T½ is 23-25hrs (term) 59-109 hrs (preterm). CSF penetration is excellent.
7.5 mg/kg q12h
7.5 mg/kg q12h
7.5 mg/kg q12h
7.5 mg/kg q12h
Infuse over 30 min.
Methicillin
IV, IM
25-50 mg/kg q12h
25-50 mg/kg q8h
25-50 mg/kg q8h
25-50 mg/kg q6h
Double the dose for meningitis. Hematuria, nephritis, reversible BM suppression, eosinophilia, rash.
Mezlocillin
IV
75mg/kg q12h
75mg/kg q8h
75mg/kg q12h
75mg/kg q6h
Allergic reaction, seizures, vomiting and hematological abnormalities (eosinophilia, leukopenia, neutropenia, anaemia) elevated BUN, creatinine and liver enzymes.
8
Moxalactum
IV, IM
50 mg/kg q12h
50 mg/kg q8h
50 mg/kg q12h
150 mg/kg/ q8h
Nafcillin
IV
25 mg/kg q12h
25 mg/kg q8h
25 mg/kg q8h
25 mg/kg q6h
Similar to penicillin. Use with caution in infants with compromised hepatic function. Good CSF penetration.
Neomycin sulfate
PO
12.5 mg/kg q6h
12.5 mg/kg q6h
12.5 mg/kg q6h
12.5 mg/kg q6h
Ototoxicity and nephrotoxicity
Netilmycin (netromycin) (10mg, 25mg 50mg in 1 ml)
IV
3.5 mg/kg q12h
3.5 mg/kg q8h
3.5 mg/kg q12h
3.5 mg/kg q8h
Theurapeutic range 10-12 mg/L (peak) and <2mg/L (trough). Active against most gram-negative and some grampositive organisms, including some which are resistant to other aminoglycosides. Activity is also seen against Pseudomonas, methicillin resistant strains of Staph aureus and Proteus. Not active against streptococci or anaerobes.
Do not mix with other antimicrobials
Nystatin
PO
Topical
400,000-800,000 units/day d/v q6h (100,000 U/ml suspension) after feeds.
Applied as ointment or cream 3–4 times daily (100,000U/g)
It is poorly absorbed from GI tract.
Oxacillin
IV, IM
25 mg/kg q12h
25 mg/kg q8h
25 mg/kg q8h
25 mg/kg q6h
May cause thrombophlebitis and Clostridium difficile colitis. Limited experience in neonates.
Palivizumab (synagis)
IM
15 mg/kg once a month during RSV season (Nov-Apr)
Preferred over anterolateral aspect of thigh.
Penicillin G (benzyl)
IV Meningitis
50,000 u/kg 12h
50,000 u/kg 12h
50,000 u/kg 12h
50,000 u/kg 12h
Active against few gram-positive and gram-negative bacteriae. Useful against Streptococci and pneumococci, congenital syphilis, tetanus, listeria and few anaerobes (gas gangrene). Diffuses well into tissues and body fluids, but penetration into the CSF is poor except when the meninges are inflamed.
Other diseases
25,000 u/kg q12h
25,000 u/kg q8h
25,000 u/kg q8h
25,000 u/kg q6h
Penicillin G (procaine) (Bisterpen)
IM
50,000 U/kg OD
50,000 U/kg OD
50,000 U/kg OD
50,000 U/kg OD
Penicillin Benzathine (Penidure)
IM
50,000 U (one dose only)
50,000 U (one dose only)
50,000 U (one dose only)
50,000 U (one dose only)
Penicillin V (keypen)
PO
62.5 mg/kg q6h
62.5 mg/kg q6h
62.5 mg/kg q6h
62.5 mg/kg q6h
Penicillin (piprapen) ureidopeni-
IV, IM
200 mg/kg/d q8h
200 mg/kg/d q6h
300 mg/kg/d q8h
300 mg/kg/d q6h
May increase the risk of haemorrhage with high doses. Active against all major gram-positive
9
cillin. (with tazobaltam) (2.25 gm vial)
and gram-negative organisms except those producing beta-lactamases. It has a good antipseudomonas cover.
Polymyxin B sulfate (poly-B)
PO, IM, IV
2.5 mg/kg q12h
2.5 mg/kg q12h
2.5 mg/kg q12h
2.5 mg/kg q8h
Does not cross blood-brain barrier. Synergy with trimethoprim and useful combination with rifampicin, especially in treatment of multiresistant strains.
Pyrimethamine PO 25 mg tab.
PO
Toxoplasmosis: Loading: 2 mg/kg OD for 2 days Maintenance: 1 mg/kg OD for 2 − 6 month, then 3 days per week to complete 12 m treatment
Supplement with folinic acid. Glossitis, seizures and rash.
Rifampicin PO (R-cin)
PO
10 mg/kg once daily
10 mg/kg q12h
10 mg/kg once daily
10 mg/kg q12h
Ribavirin (Ribavin)
Aerosol
Administer using a (SPAG −2) small particle aerosol generator provided by the company. The drug is delivered via an oxygen hood or through the inhalation tubing of a ventilator. Concentration of drug in reservoir (20 mg/ml) is not varied with patient weight. Treatment is carried out for 12–18 hours per day for 3–7 days.
Rash and conjunctivitis have been observed. Special precautionary measures need to be taken when drug is being given through a ventilator to avoid drug deposition and consequent malfunctioning of expiratory valve.
Spiramycin (Rovamycin) Macrolide (0.75 million IU tab)
PO
Immunocompromised: 0.75million IU/day d/v q8h for 5 days
Toxoplasmosis: 0.15-0.30 million IU/kg/day d/v q12h for 6 wk
Meningococcal meningitis prophylaxis: 150000 IU/kg/day for 5 days
Active against streptococci, staphylococci, diphtheria, pertusis, Listeria, Clostridia, Legionella, chlamydia, mycoplasma, N. meningitides, Toxoplasma gondii and Cryptosporidia. Not active against gram-negative aerobes. Synergism with metronidazole against anaerobes seen.
Ticarcillin
IV, IM
75 mg/kg q12h
75 mg/kg q8h
75 mg/kg q8h
75 mg/kg q8h
Active against Pseudomonas
Ticarcillin + clavulanic acid (Timentin)
IV
75 mg/kg q12h
75 mg/kg q8h
75 mg/kg q8h
75 mg/kg q6h
Hypersensitivity reaction, phlebitis, pseudomembranous colitis, hypernatremia and inhibition of platelet aggregation. Monitor renal function.
Tobramycin (tobacin tobraneg) Aminoglycoside (10 mg/ml 1 ml, 2 ml vial)
IV, IM
2 mg/kg q24h
2 mg/kg q12h
2 mg/kg q12h
2 mg/kg q8h
More active against Pseudomonas. Active against Staphylococcus aureus, E. coli, Klebsiella, Proteus, Serratia and Citrobacter ototoxicity and impaired renal function. Less active against streptococcus. Adjust dose in renal failure.
Vancomycin IV (vancorin) (500 mg vial)
IV
Recommended dosage designed to achieve one hour post infusion levels of 25-30 mg/L, trough levels of 5-10 mg/L and average vancomycin serum Concetrations at steady state of 13.5 mg/L, immediate post infusion. Vancomycin serum concentrations are predicted to be < 40 mg/L.
Infuse over 60min to avoid Redman's syndrome; increase dose in CNS infections to 60 mg/kg/day d/v q6h. Active only against gram-positive
10
Dose (mg/kg/dose)
Dosing Interval
bacteria. Mainly used against penicillin-resistant staphylococci (Staphylococcus aureus, coagulase-negative staphylococci, streptococci and grampositive anaerobes including Clostridium difficile)
<27 wk
27
q36h
27-30 wk
24
q24h
31-36 wk
27
q18h
>37 wk
22.5
q12h
Dilute with NS or DS to give 5 mg in 1 ml. infuse over 1 hour
Vidarabine
IV
<1 month: 15-30 mg/kg/day infused over 12-24 hour period for 10 consecutive days. (Minimum dilution is 0.45 mg/ml of IV fluid. In line filter > 0.45 micron recommended)
Adverse reactions noted in adults; nausea, vomiting diarrhoea, rash, ataxia, tremors, myoclonus and bone marrow depression. These have not been observed in neonates. Monitor hematologic, renal and hepatic status. Reduces dose by 25% in severe renal failure.
Zidovudine (retrovir) 10 mg/ml, susp. and Inj.
PO IV
2 mg/kg 6h for 6 wk
1.5 mg/kg 6h for 6 wk
Severe anaemia, neutropenia, GI upset.
*All dose in mg/kg/dose, unless mentioned specifically. q8h indicates interval between doses.
Comments code for anti-bacterial agents:
  1. Increase dosing interval in renal impairment.
  2. Reduce dose in liver impairment.
  3. Monitoring of serum drug concentration recommended.
  4. Check special protocol for administration.
  5. Close clinical monitoring for dose related and ldiosyncratic toxicity recommended.
  6. Inadequate pharmacokinetic studies in neonates; only indicated in very unusual situations.
Clearance of amikacin, gentamicin and vancomycin is influenced both by the gestational age (GA) and the postnatal age. Therefore in infant s> 7 days old, it might be useful to consider the postconceptional age (PCA) in the dosing schedule. Please note the dosage is in mg/kg/ dose.
11
 
Organisms generally susceptible to penicillins
Gram-positive
Organisms
Natural penicillins
Penicillinase resistant
Aminopenicillins
Extended spectrum
Penicillin G
Penicillin V
Cloxacillin
Amoxicillin
Ampicillin
Bacampicillin
Amoxicillin/pot. Clavulanate
Ampicillin/ sulbactam
Carbenicillin
Piperacillin
Ticarcillin
✓=generally susceptible
Staphylococci
1
1
1
1
1
1
1
1
Staphylococcus aureus
1
1
1
1
1
Streptococci
Streptococcus pneumoniae
Beta-hemolytic streptococci
Streptococcus faecalis
Streptococcus viridans
Corynebacterium diphtheriae
Bacillus anthracis
Listeria monocytogenes
Gram-negative
Escherichia coli
Haemophilus influenzae
2
Klebsiella sp
Neisseria gonorrhoeae
1
Neisseria meningitis
Proteus mirabilis
Salmonella sp
Shigella sp
Morganella morganii
Proteus vulgaris
Providencia sp
Providencia rettgeri
Providencia stuarti
Enterobacter sp
Citrobacter sp
Pseudomonas aeruginosa
Serratia sp
Acinetobacter sp
Streptobacillus moniliformis
Moraxella (Branhamella) catarrhalis
12
Anaerobic
Clostridium sp
Peptococcus sp
Peptocostreptococcus sp
Bacteroides sp
3
Fusobacterium sp
Eubacterium sp
Treponema pallidum
Actinimyces bovis
Veillonella sp
  1. Non–penicillinase–producing.
  2. Non–beta–lactamase–producing.
  3. B fragilis is resistant.
13
 
Organisms generally susceptible to cephalosporins
Organisms
First generation
Second generation
Third generation
✓=generally susceptible
+ = demonstrated in vitro activity
Cephalexin
Cefadroxil
Cefazolin
Cefaclor
Cefuroxime
Cefonicid
Cefixime
Cefoperazone
Cefotazime
Ceftizoxime
Ceftriaxone
Ceftazidime
Gram-positive
Staphylococci1
2
2
2
3
Staphylococci, beta-hemolytic
Streptococcus pneumoniae
Streptococcus pyogenes
Acinetobacter sp
2
+
+
Gram-negative
Citrobacter sp
2
+
+
+
+
Enterobacter sp
2
2
+
Escherichia coli
Haemophilus influenzae
3
3
3
3
3
3
3
3
3
3
Haemophilus parainfluenzae
+
+3
+
Hafnia alvei
Klebsiella sp
+
Moraxella (Branhamella) catarrhalis
+
+
2
+
Morganella (Proteus) morganii
2
+
Neisseria gonorrhoeae
+
+
+
3
+
Proteus mirabilis
Proteus vulgaris
+
Providencia sp
+
+
+
+
+
Providencia rettgeri
+
+
+
Pseudomonas aeruginosa
2
2
2
Salmonella sp
+
+
+
+
+
+
Salmonella typhi
+
+
+
Serratia sp
+
Shigella sp
+
+
+
+
+
+
Anaerobic
Bacteroides sp
+
Bacteroides fragilis
+
Clostridium sp
+
+
+
+
Clostridium difficile
+
Eubacterium sp
+
+
Fusobacterium sp
+
+
+
+
Peptococcus sp
+
+
+
+
Peptostreptococcus sp
+
+
+
+
  1. Coagulase–positive, coagulase–negative and penicillinase–producing.
  2. Some strains are resistant.
  3. Including some β–lactamase–producing strains.
14
 
Significance of blood culture isolates
Significance
Organisms
Almost always significant
Group B Streptococcus
Streptococcus pneumoniae
Listeria monocytogenes
Haemophilus influenzae
Enterococci (Streptococcus faecalis, S. faecium,
S. Bovis, etc).
Group A Streptococcus
Group C/G streptococci
Neisseria meningitidis
Neisseria gonorrhoea
Gram–negative bacilli
Candida and other fungi
Sometimes significant (about 50%)
Staphylococcus aureus
Coagulase–negative staphylococci (S. epidermidis etc.)
Streptococcus viridans group (including S. mitis, S. mitior,
S. milleri, S. Sanguis, etc)a
Clostridium species
Multiple isolates (polymicrobial)
Almost always contaminats
Diphtheroids
Propionibacterium
Bacillus species
 
Antibiotic guidelines in neonatal infection
Clinical Situations
Risk Factors
Possible Organisms
Suggested Regimes
Comments
‘Early’ onset sepsis/? RDS
PROM > 24 hr Maternal infection–fever, leucocytosis etc.
Maternal colonisation
GBS
E. coli
Other enterobacteria
Benzylpenicillin + gentamicin
If all cultures subsequently prove negative, antibiotics can be stopped after 48 hours if the baby is well proven septicaemia is usually treated for 10 days
Offensive or green liquor
Listeria monocytogenes
Benzylpenicillin + gentamcin
Convert penicillin to Ampicillin following confirmation of diagnosis
Sepsis after >5 days
Presence of septic spots,
Umbillical flare, central venous line in situ
Staph aureus staph
Spp
Other gram-positive and - negative organisms
Flucloxacillin + gentamicin
In proven S. Epidermidis
Septicaemia secondary
To long – line
Sepsis, change to vancomycin if symptoms not resolved by 48 hrs
Pneumonia after prolonged stay in the neonatal unit
Ventilated
Earlier course of antibiotics Last ET
Aspirate
Not available, no growth or Staphylococcus
Flucloxacillin + gentamicin
Conjuctivitis/Pneumonitis
Coliforms
Pseudomonas
Aeruginosa
Chlamydia
Cefotaxime
Ceftazidime + gentamicin
Erythromycin
Necrotising enterocolitis
Preterm
Birth asphyxia
Umbilical catheterisation
`Gut organisms’ including anaerobes
Benzylpenicillin + gentamicin+
Metronidazole Or cefotaxime and metronidazole
Urinary tract infection
Commoner in males CSF
E. coli other enterobacteria
GBS
Ampicillin + gentamicin
Benzylpenicillin
15
Meningitis
Gram film:
Gram-positive cocci in chains: Gram-negative bacilli, gram-positive bacilli
+ gentamicin
No bacteria seen
Coliforms
Listeria monocytogenes
Cefotaxime and gentamicin
Ampicillin and gentamicin
Cefotaxime and gentamicin
Change according to culture and sensitivity results
 
Septic risk scoring
0
1
2
Phase I
Duration of ROM (hour)
<12
12-24
>24
Maternal temperature (F)
98-99
99-100
>100
Apgar score at 5 minutes
08-10
05-07
<5
Amniotic fluid appearance
Clear
Meconium or blood-stained
Purulent or foul smelling
Weight of infant (g)
>2500
1500-2500
<1500
Phase II
Appearance of placenta
Clear
opalescent
Purulent
Gastric aspirate PMN count
0-5
6-15
>15 or bacteria engulfed in PMN
Maternal temperature (F)
1–2 hours postpartum
98–99
99–100
>100
Material WBC on
day of delivery (mm3)
10,000–15,000
15,000–20,000
>20,000
Maternal urinalysis (microscopic)
Clear
Bacteria or white cells
Both bacteria and white cells
State of infant
Normal
Questionable
Respiratory distress or lethargy
 
Specific antibiotic therapy in early-onset neonatal septicemia
First line
Ampicillin + gentamicin / amikacin (to cover most Gram-positive and Gram-negative pathogens)
In ampicillin resistance
A third generation cephalosporin + gentamicin / amikacin
In accompanying meningitis
Ampicillin / amikacin + a third generation cephalosporin
 
Specific antibiotic therapy in late-onset neonatal septicemia
First line
Ampicillin + gentamicin/amikacin
Second line
Cefotaxime + amikacin. Add cloxacillin if staph is suspected. For resistant staph, vancomycin or coamoxyclav should be preferred.
For nosocomial infections
Ceftazidime or cefoperazone + netilmicin
 
Suggested antibiotic regimens for sepsis and meningitis
Organism
Antibiotic
Bacteremia
Meningitis
GBS
Ampicillin or penicillin G
10-14 days
21 days
E. coli
Cefotaxime or ampicillin and gentamicin
14 days
14 days
21 days
21 days
Enterobacter, Klebsiella
Cefotaxime or cefipime or meropenem and gentamicin
14 days
21 days
Enterococcus
Ampicillin or vancomyin and gentamicin
10 days
21 days
Listeria
Ampicillin and gentamicin
10–14 days
21 days
Pseudomonas
Ceftazidime or piperacillin / tazobactam and gentamicin or tobramycin
14 days
21 days
S. aureus
Nafcillin
10-14 days
21 days
16
 
FIRST LINE ANTIBIOTICS
These are suggetions for initial treatment until sensitivity test results are available:
Acinetobacter: Ticarcillin +/− tobramycin.
Actinomyces isralli: Benzylypenicillin.
Aeromonas: Cotrimoxazole.
Afipla felis (cat scratch): Ciprofloxacin or cotrimoxazole.
Bacillus anthracis: Benzylpenicillin.
Bacteroides: oral: Benzylpenicillin metronidazole.
Bordetella pertusis: Erythromycin.
Borrelia burgdorferi (Lyme disease): Tetracycline or ceftriaxone.
Borellia recurrents (relapsing fever): Tetracycline or benzylpenicillin.
Branhamella catarrahalis: See moxarella catarrhalis.
Brucella: Tetracycline + gentamicin, or cotrimoxazole.
Calymmatobacterium granulomatis (granuloma inguinale): Tetracycline.
Campylobacter jejuni: Ciprofloxacin or erythromycin.
Chlamydia pneumoniae (TWAR strain): Tetracycline or erythromycin.
Chlamydia psittaci (psittacosis, ornithosis): Tetracycline or erythromycin.
Chlamydia trachomatis: Erythromycin. Trachoma: Topical and oral tetracycline or sulphonamide.
Clostridia: Benzylpenicillin. Clostridium difficile: Vancomycin or metronidazole.
Botulism: Oral vancomycin.
Corynebacteria: Erythromycin. JK group: Vancomycin.
Eikenella corrodens: Amoxycillin +/− clavulanic acid.
Enterobacter: Cefotaxime + amikacin.
Escherichia Coli: Cefotaxime +/− gentamycin
Francisella tularensis (tularaemia): Gentamicin.
Fusobacterium: Benzylpenicillin.
Gardnerella (haemophilus) vaginalis: Metronidazole.
Haemophilus ducreyi (chancroid): Erythromycin.
Haemophilus influenzae: Cotrimoxazole. Severe inftn: Cefotaxime or ceftriaxone.
Klebsiella pneumoniae: Cefotaxime +/− gentamicin.
Legionella: Erythromycin + rifampicin.
Leptospira: Benzylpenicillin.
Leptotrichia buccalis: Benzylpenicillin.
Listeria: Monocytogenes: Amoxycillin +/− gentamicin.
Morganella morganil: Cefotaxime +/− gentamicin.
Moxarella catarrhalis: Cotrimoxazole or cefotaxime.
Mycoplasma pneumoniae: Erythomycin or tetracycline.
Neisseria gonorrhoeae: Ceftriaxone.
Neisseria meningitides: Benzylpenicillin.
Nocardia: Cotrimoxazole.
Pasturella multocida: Benzylpenicillin.
Proteus: Cefotaxime +/− gentamicin. Indole negative: Amoxycillin.
Providencia: Cefataxime +/− gentamicin.
Pseudomonas cepacia: Cotrimoxazole.
Pseudomonas mallei (glanders): Streptomycin + either tetracycline or chloramphenicol.
Pseudomonas maltophilla: See xanthomonas maltophilia.
Pseudomonas pseudomallei (melioidosis): Ceftazidime.
Rickettsia: Tetracycline or chloramphenicol.
Rochalimaea henselae (bacillary angioniatosis): Erythromycin.
Salmonella: Cefotaxime. S.typhi: Ceftriaxone.
Serratia: Cefotaxime +/− gentamicin.
Shigella: Ciprofloxacin or cotrimoxazole or amoxycillin or ceftriaxone.
Spirillum minus (rat bite fever): Benzylpenicillin.17
Staphylococcus: Flucloxacillin +/− gentamicin. Resistant: Vancomycin +/− gentamicin and/or rifampicin.
Streptobacillus moniliformis (rat bite fever): Benzylpenicillin.
Streptococcus: Benzylpenicillin. Enterococcus: Amoxycillin + gentamicin or amikacin. S. Viridans: Benzylpenicillin +/− gentamicin.
Treponema pallidum (syphilis): Benzylpenicillin.
Treponema partenue (yaws): Benzylpenicillin.
Ureaplasma urealyticum: Erythromycin.
Vibrio cholerre (cholere): Tetracycline or cotrimoxazole
Vibrio vulnificus: Tetracycline or cefotaxime.
Xanthomonas maltophilia: Cotrimoxazole.
Yersinia enterocolitica: Cotrimoxazole.
Yersinia pestis (plague): Streptomycin.
 
Viral Infection Therapy
Viral infection
Prevention/therapy
Hepatitis B virus
Hepatitis B immunoglobulin
Hepatitis B vaccine
Herpes simplex virus
Acyclovir
Vidarabine
Varicella-zoster virus
Acyclovir
Vidarabine
Respiratory syncytial virus
Ribavrin (aerosol)
Cytomegalovirus
Ganciclovir (potential)
Human immunodeficiency virus
Azidothymidine (AZT) (Potential)