Recommended Antimicrobial Dosage Schedules for Neonates

Jeffrey L. Segar, MD, Chetan A. Patel, and Sarah B. Tierney, PharmD.

Peer Review Status: Internally Peer Reviewed 3/26/12

Drug
Acyclovir

Amikacin*

Amoxicillin

Dosage

Major Indications / Remarks

20 mg/kg/dose q 8 hr IV
Administer over 1 hour

Herpes Simplex & Varicella.

Increase dosing interval with <34 wk
gestation or with significant renal /
hepatic failure
Treat localized infections for 14 days;
disseminated or CNS infections for 21
days.

Give IV or IM
PMA
Postnatal
Dose
(weeks)
(days)
(mg/kg)
29
0 to 7
18
8 to 28
15
29
15
30 to
0 to 7
18
34
8
15
35
ALL
15
Administer over 30 minutes

Interval
(hrs)
48
36
24
36
24
24

Gram negative enteric bacteria

peak 20-30, trough 2-5 mcg/ml
Usually used in combination with a betalactam antibiotic.

20 mg/kg/dose q HS PO

UTI prophylaxis

test dose: 0.1 mg/kg IV

initial dose: 0.25 mg/kg IV
increment : 0.125 - 0.25 gm/kg/d IV
maintenance dose: 1 mg/kg/d qd or 1.5
mg/kg/d qod IV
Administer over 2-6 hours

Most systemic fungal infections &

severe superficial mycoses. Decreases
renal blood flow / GFR; Monitor renal /
hepatic status closely.
total dose: 15-30 mg/kg

Ampicillin

Mild/Moderate infection: 100 mg/kg/dose

IV
Meningitis:400 mg/kg/d q 8-12 hr IV
See Table 2 for dosing interval
Administer by IV push over 3-5 minutes

Group B streptococcus, enterococcus,

E coli, Listeria monocytogenes

Aztreonam

30 mg/kg/dose IV or IM
Administer slow IV push over 5-10
minutes
See Table 2 for dosing interval

Gram negative organisms. Generally

used in combination with ampicillin
(empirical treatment of sepsis) or an
aminoglycoside (for synergism against
Pseudomonas and Enterobacteriaceae).
Check serum glucose 1 hour after
administration. Aztreonam contains Larginine so adequate amounts of glucose
must be provided to prevent
hypoglycemia.

25 mg/m2 (or approximately 2 mg/kg) IV

per dose q24 hours
Administer over 1 hour

Antifungal agent for refractory Candida

or invasive Aspergillosis refractory or
intolerant to other therapies.

Amphotericin B

Caspofungin

Max concentration 0.5 mg/ml diluted in an

NS product; not dextrose
Cefazolin

25 mg/kg/dose IV slow push or IM

See Table 2 for dosing interval

1st generation cephalosporin. Gram +

cocci ; may cause false positive urine
reducing substance. Poor CNS
penetration.

Cefepime

28 days: 30 mg/kg/dose q 12 hr IV or IM
>28 days: 50 mg/kg/dose q 12 hr IV or IM
Meningitis and severe infections: 50
mg/kg/dose q 8 hr IV or IM
Administer IV over 30 minutes

4th-generation cephalosporin for serious

gram-positive and gram-negative
infections, especially Pseudomonas
aeruginosa. Drug distributes widely in
body tissues and fluids.

Cefotaxime

50 mg/kg dose IV or IM
See Table 2 for dosing interval
Administer IV over 30 minutes

3rd-generation cephalosporin. Treatment

of gram-negative enteric bacteria.
Penetrates well across BBB and good for
use in meningitis

Cefoxitin

30 mg/kg/dose IV or IM
See Table 2 for dosing interval
Administer IV over 30 minutes

2nd-generation cephalosporin with

enhanced activity against anaerobic
bacteria. Poor CNS penetration.
Treatment usually limited to skin, intraabdominal, and urinary tract infections.

Ceftazidime

Sepsis 0-4 weeks: 30 mg/kg/dose IV

Meningitis: 50 mg/kg/dose IV
See Table 2 for dosing interval
Administer IV over 30 minutes

3rd-generation cephalosporin for gramnegative esp. Pseudomonas: Consider

two antibiotics with positive
Pseudomonas cultures. Synergistic with
aminoglycosides.

Ceftriaxone

Sepsis/Disseminated gonococcal infections:

50 mg/kg q 24 hours IV or IM
Meningitis: 100 mg/kg loading dose than
80 mg/kg q 24 hours IV or IM.
Uncomplicated gonococcal ophthalmia: 50
mg/kg (max 125 mg) once IV or IM.
Administer IV over 30 minutes

3rd-generation cephalosporin for gramnegative bacteria and gonococcal

infection. Widely distributes. Not
recommended for use in neonates with
hyperbilirubinemia. Concurrent
administration with calcium-containing
products in neonates is contraindicated.

Cefuroxime

15 mg/kg/dose qHS PO

UTI Prophylaxis

Cephalexin

10-20 mg/kg/dose qHS PO

UTI Prophylaxis
Can alternate with or change to Bactrim
at 2 months of life

5 to 7.5 mg/kg/dose IV, IM, or PO

See Table 2 for dosing interval
Administer IV over 30 minutes

Gram-positive cocci and bacteroides.

Widely distributes to most tissues, esp
the lungs. Poor CSF penetration.
Psuedomembranous colitis most serious
adverse effect bloody diarrhea, fever

10-15 mg/kg q 6-12 hr PO

Do NOT administer IM

Chlamydia and Mycoplasma

Risk of hypertrophic pyloric stenosis is
increased 10-fold in neonates < 2 weeks
who receive oral erythromycin for

Clindamycin

Erythromycin

pertussis prophylaxis.
Fluconazole

Treatment: 12 mg/kg loading dose, then 6

mg/kg IV or PO
Prophylaxis: 3 mg/kg/dose 2x/wk IV or PO
Thrush: 6 mg/kg LD, then 3 mg/kg/dose qd
PO
Gest Age
PostNatal
Interval
(weeks)
(days)
(hours)
29
0 to 14
48
>14
24
>30
0 to 7
48
>7
24
Administer IV over 60 minutes

Antifungal for Candida species. Monitor

renal and hepatic function. Extended
dosing interval when SCr >1.3. PO/IV
both well-absorbed and distributes
widely, incl. CSF. May increase levels of
phenytoin and rifampin. Use with
Cisapride contraindicated.

Flucytosine

12.5 to 37.5 mg/kg/dose q 6 hours PO

Increase dosing interval if renal
dysfunction is present.

Antifungal for Candida, Cryptococcus.

Must be used in combination with
amphotericin B of fluconazole due to
development of resistance. Toxicities
include impaired renal function, fatal
bone marrow depression, hepatitis,
severe diarrhea, rash.

Ganciclovir

6 mg/kg/dose q12 hours IV

Treat for a minimum of 6 weeks if possible
Decrease dose by for neutropenia (<500
cells/mm3). Discontinue therapy if
neutropenia does not resolve after dose
reduction.
Administer over 60 minutes

Prevention of progressive hearing loss

and lessening of developmental delays in
symptomatic congenital CMV.

Give IV or IM
PMA
Postnatal
Dose
(weeks)
(days)
(mg/kg)
29
0 to 7
5
8 to 28
4
29
4
30 to
0 to 7
4.5
34
8
4
35
ALL
4
Administer IV over 30 minutes

Gram negative aerobic bacilli;

Usually used in combination with a betalactam antibiotic. Administer as a
separate infusion from penicillincontaining compounds.
Ototoxic effects synergistic with lasix.
Need to monitor serum levels:
Trough: < 2, ideal 0.5 to 1.0; Peak: 512 mg/L
For high trough levels, increasing dosing
interval to next higher level is usually
sufficient - always recheck levels again
after adjusting dosage/interval

Gentamicin*

Imipenem/Cilastatin

Isoniazid

Interval
(hrs)
48
36
24
36
24
24

20-25 mg/kg/dose q12 hrs IV

Administer over 30 minutes

Non-CNS infections caused by

Enterobacteriaceae and anaerobes
resistant to other antibiotics. Seizures
common with meningitis and severe
renal dysfunction.

Treatment: 10-15 mg/kg/day PO qd or

divided BID
Prophylaxis: 10 mg/kg PO qd

Mycobacteria

Lamivudine

2 mg/kg/dose q 12 hours PO for 1 week

following birth
Used in combination with zidovudine.

Prevention of mother-to-child HIV

transmission when no other therapy
during pregnancy.

10 mg/kg/dose q8 hours PO or IV
Preterm and < 1 week give q12 hours.
Administer IV over 30 minutes.

Gram-positive organisms, incl. MRSA,

refractory to vancomycin and other
antibiotics. Not used for empiric
therapy.

Sepsis: 20 mg/kg/dose IV
Gest Age
Postnatal
Interval
(weeks)
(days)
(hours)
32
0 to 14
12
>14
8
>32
0 to 7
12
>7
8
Meningitis/Pseudomonas: 40 mg/kg/dose
q8 hr
Administer IV over 30 minutes

Multidrug-resistant gram-negative,
gram-positive, and anaerobic organisms.

25 - 50 mg/kg/dose IV or IM
< 2 kg: < 7 d: q12 h; > 7 d: q 8 h
> 2 kg: < 7 d: q 8 h; > 7 d: q 6 h

Penicillinase-producing Staphylococcus
aureus. Use the higher doses for
meningitis

Loading dose: 15 mg/kg IV/PO

Maintenance dose: 7.5 mg/kg IV/PO
PMA
Postnatal
Interval
(weeks)
(days)
(hours)
29
0 to 28
48
>28
24
30 to 36
0 to 14
24
>14
12
37 to 44
0 to 7
24
>7
12
44
ALL
8
Administer IV over 60 minutes

Anaerobic infections; begin maintenance

dose 48 h after load in preterm infants &
after 24 h in term infants.

Mezlocillin

50 - 100 mg/kg/dose IV / IM
See Methicillin for dosing schedule

Pseudomonas, Group B Strep, most

Klebsiella pneumoniae and Serratia
marcescens

Mupirocin

Apply small amount topically to affected

area q8 hours for 5-14 days.

MRSA topical infections. Do not apply

to the eye. May cover with gauze.

Usual: 25 mg/kg/dose IV
Meningitis: 50 mg/kg/dose IV
See Table 3 for dosing interval
Administer IV over 15 minutes

Penicillinase-producing Staphylococcus
aureus. Use nafcillin for renal
dysfunction pts.

2 mg/kg PO once at 48 to 72 hours of age.

If mother did not receive intrapartum
single-dose nevirapine, administer 2 mg/kg
as soon as possible after birth.

Used ONLY in combination with

zidovudine in treatment of neonates born
to HIV-infected women who had no
therapy during pregnancy.

Preterm: 0.5 mL PO q6 hours

Mucocutaneous candida infections.

Linezolid

Meropenem

Methicillin

Metronidazole

Nafcillin

Nevirapine

Nystatin

Term: 1 mL PO q6 hours
Apply topically with swap to each side of
mouth. Use for length of antibiotic therapy
and continue for 24 hours after
discontinuation of antibiotic therapy,
especially in infants <1500 grams.

Prophylaxis against invasive fungal

infections in VLBW infants. Do not
need if using fluconazole.

25 mg/kg/dose IV or IM
Meningitis: 50 mg/kg/dose IV or IM
See Table 3 for dosing interval
Administer IV over 10 minutes

Penicillinase-producing Staphylococcus
Aureus. Interstitial nephritis.

See Table 3 for dosing interval

Non-producing Penicillinase organisms

Pen G: Meningitis

75,000 - 100,000 IU/kg/dose IV or IM

Administer IV over 30 minutes

See Methicillin for dosing schedule

25,000 - 50,000 IU/kg/dose IV or IM

Administer IV over 15 minutes

Treatment of susceptible organisms:

streptococci , cong. syphilis, gonococci

Oxacillin

Penicillins

Pen G: Sepsis

For Group B Strep sepsis: 200,000 IU/kg/d

in divided doses and 400,000 IU/kg/d in
divided doses with meningitis

50,000 units/kg one dose, IM only

50,000 U/kg IM q wk x 3 doses

Syphilis (No clinical findings and only if

follow-up cannot be ensured)
Syphilis > 1 yr. in mother

Procaine

50,000 units/kg q day, IM only

Syphilis

Piperacillin

50 to 100 mg/kg/dose IV or IM
See Table 3 for dosing interval
Administer IV over 30 minutes

Gram-positive, gram-negative, anaerobic

incl. Pseudomonas and Group B Strep.

Piperacillin-Tazobactam
(Zosyn)

50 to 100 mg/kg/dose IV or IM
See Table 3 for dosing interval
Administer IV over 30 minutes

Gram-positive, gram-negative, anaerobic

incl. Pseudomonas and Group B Strep.
Non-CNS infections.

Ribavirin

Dilute 6 gm in 300 ml sterile water.

Administer by aerosol over 12 - 18 hr
daily for 3 - 7 days

Respiratory syncytial virus (severe

herpes). Most effective if begun early in
course of illness. May worsen respiratory
distress. Should be administered in a
well-ventilated room. Women of childbearing age should not administer.

Rifampin

PO: 10 -20 mg/kg q24 hr.

IV: 5 - 10 mg/kg q 12 hr
Administer IV over 30 minutes

Mycobacteria; causes red discoloration

of body secretions. Must be used in
combination with vancomycin or
aminoglycosides for persistent
staphylococcal infections. Causes
orange/red discoloration of body
secretions. Potent inducer of P450.

Benzathine

Ticarcillin -Clavulanate

Tobramycin*

TrimethoprimSulfamethoxazole
(Bactrim)
Valganciclovir

Vancomycin*

Zidovudine

75-100 mg/kg/dose IV
See Table 3 for dosing interval
Administer IV over 30 minutes

Pseudomonas
may cause decreased platelet
aggregation, bleeding diathesis,
hypernatremia, hypocalcemia, increased
AST

See Gentamicin for dosing schedule

Administer IV over 30 minutes

Aerobic gram-negative bacilli (e.g., E

coli, Pseudomonas, Klebsiella)
Need to monitor levels
Trough: < 2 mg/L, ideal 0.5 -1.0. Peak:
5 - 12 mg/L

Prophylaxis: 2 mg/kg qHS PO

Treatment: 4 mg/kg q12 hours PO

UTI caused by E.coli, Klebsiella,

Enterobacter, Proteus
Contraindicated < 2 months

16 mg/kg/dose PO q12 hours.

Treat for a minimum of 6 weeks. Prodrug
of ganciclovir.

Neutropenia common.
If ANC<500 hold until >750
If ANC<750, reduce dose by 50%
If ANC<500 again, discontinue.

10-15 mg/kg/dose IV
PMA
Postnatal
Interval
(weeks)
(days)
(hours)
29
0 to 14
18
>14
12
30 to 36
0 to 14
12
>14
8
37 to 44
0 to 7
12
>7
8
45
ALL
6
Administer IV over 90 minutes

Methicillin-resistant staphylococci (e.g.,

S aureus and S epidermidis) and
penicillin-resistant pneumococci. Note:
Red man syndrome results from rapid IV
infusion.
Need to monitor serum levels
Trough: 5-10 mg/L; Peak: 25 - 40 mg/L
Give 15 mg/kg/dose if CNS infection

IV: 1.5 mg/kg/dose over 60 minutes

PO: 2 mg/kg/dose.
Do not give IM
Begin treatment 6-12 hours after birth and
continue for 6 weeks.

Treatment of HIV infection in

combination with other antiretroviral
agents.
Initiation of therapy after age 2 days is
not likely to be effective.

* Serum drug level monitoring recommended. See document Use of Drug Monitoring Levels in the NICU for
appropriate procedures.
Table 2: Dosing Interval Chart
Gest. age Postnatal age Interval (q)
< 29 wk
0 to 28 d
12 hr
> 28 d
8 hr
30 to 36 wk 0 to 14 d
12 hr
> 14 d
8 hr
37 wk
0 to 7 d
12 hr
>7d
8 hr

Table 3: Dosing Interval Chart

PMA
Postnatal
Interval
(weeks)
(days)
(hours)
29
0 to 28
12
>28
8
30 to 36
0 to 14
12
>14
8
37 to 44
0 to 7
12
>7
8
45
ALL
6

Table 4: Usual Therapeutic Range

PEAK (g/ml)
Gentamicin
5-12
Tobramycin
5-12
Kanamycin
20-25
Amikacin
20-30
Vancomycin
25-40

TROUGH (g/ml)
0.5-1.0
0.5-1.0
5-10
2-5
5-10

These data represent usual starting and maintenance doses for seriously compromised infants or LBW
weight premature infants (< 2 kg or <34 wk. gestation) and full-term infants.
Monitoring of serum drug levels will assist in optimizing dosage adjustments, particularly with changing
organ function as the newborn matures or recovers from the initial illness.
Optimum time to obtain levels is 30 min. prior to next dose for trough levels, and 30 minutes after
completion of IV infusion for peak levels.
With high serum levels, usually an increase in interval of administration is warranted rather than lowering
of individual dose, although both may be necessary in some neonates.

References
1. Young TE, Mangum B. Neofax A manual of drugs used in neonatal care. 23rd edition, Columbus, Ohio;
Ross Laboratories, 2010..
2. Johnson KB. The Harriet Lane Handbook. 13th edition. Mosby - Year Book, Inc., St Louis, MO, 1993
Brown & Campoli-Richards, 1989; (4) Beretz & Tato, 1988; and (5) Remington & Klein, 1990.
3. MICROMEDEX. Accessed online 2012. Updated annually.
4. Taketomo CK, Hodding JH, Kraus DM. Lexi-Comp:Pediatric Dosage Handbook. Accessed online 2012.
Updated annually.