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 Dosage Major Indications / Remarks

Acyclovir 20 mg/kg/dose q 8 hr IV Herpes Simplex & Varicella.

Administer over 1 hour
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.

Amikacin* Give IV or IM Gram negative enteric bacteria

PMA Postnatal Dose Interval peak 20-30, trough 2-5 mcg/ml
(weeks) (days) (mg/kg) (hrs) Usually used in combination with a beta-
≤29 0 to 7 18 48 lactam antibiotic.
8 to 28 15 36
≥29 15 24
30 to 0 to 7 18 36
34 ≥8 15 24
≥35 ALL 15 24
Administer over 30 minutes

Amoxicillin 20 mg/kg/dose q HS PO UTI prophylaxis

Amphotericin B 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 Group B streptococcus, enterococcus,

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

Aztreonam 30 mg/kg/dose IV or IM Gram negative organisms. Generally

Administer slow IV push over 5-10
minutes
See Table 2 for dosing interval
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 L-
arginine so adequate amounts of glucose
must be provided to prevent
hypoglycemia.

Caspofungin 25 mg/m2 (or approximately 2 mg/kg) IV Antifungal agent for refractory Candida
per dose q24 hours or invasive Aspergillosis refractory or
Administer over 1 hour intolerant to other therapies.
 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
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
Cefotaxime 50 mg/kg dose IV or IM
See Table 2 for dosing interval
Administer IV over 30 minutes
Cefoxitin 30 mg/kg/dose IV or IM
See Table 2 for dosing interval
Administer IV over 30 minutes
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
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
Cefuroxime 15 mg/kg/dose qHS PO
Cephalexin 10-20 mg/kg/dose qHS PO
Clindamycin 5 to 7.5 mg/kg/dose IV, IM, or PO
See Table 2 for dosing interval
Administer IV over 30 minutes
Erythromycin 10-15 mg/kg q 6-12 hr PO
Do NOT administer IM
1st generation cephalosporin. Gram +
cocci ; may cause false positive urine
reducing substance. Poor CNS
penetration.
4th-generation cephalosporin for serious
gram-positive and gram-negative
infections, especially Pseudomonas
aeruginosa. Drug distributes widely in
body tissues and fluids.
3rd-generation cephalosporin. Treatment
of gram-negative enteric bacteria.
Penetrates well across BBB and good for
use in meningitis
2nd-generation cephalosporin with
enhanced activity against anaerobic
bacteria. Poor CNS penetration.
Treatment usually limited to skin, intra-
abdominal, and urinary tract infections.
3rd-generation cephalosporin for gram-
negative esp. Pseudomonas: Consider
two antibiotics with positive
Pseudomonas cultures. Synergistic with
aminoglycosides.
3rd-generation cephalosporin for gram-
negative bacteria and gonococcal
infection. Widely distributes. Not
recommended for use in neonates with
hyperbilirubinemia. Concurrent
administration with calcium-containing
products in neonates is contraindicated.
UTI Prophylaxis
UTI Prophylaxis
Can alternate with or change to Bactrim
at 2 months of life
Gram-positive cocci and bacteroides.
Widely distributes to most tissues, esp
the lungs. Poor CSF penetration.
Psuedomembranous colitis most serious
adverse effect Æ bloody diarrhea, fever
Chlamydia and Mycoplasma
Risk of hypertrophic pyloric stenosis is
increased 10-fold in neonates < 2 weeks
who receive oral erythromycin for
 pertussis prophylaxis.

Fluconazole Treatment: 12 mg/kg loading dose, then 6 Antifungal for Candida species. Monitor
mg/kg IV or PO renal and hepatic function. Extended
Prophylaxis: 3 mg/kg/dose 2x/wk IV or PO dosing interval when SCr >1.3. PO/IV
Thrush: 6 mg/kg LD, then 3 mg/kg/dose qd both well-absorbed and distributes
PO widely, incl. CSF. May increase levels of
Gest Age PostNatal Interval phenytoin and rifampin. Use with
(weeks) (days) (hours) Cisapride contraindicated.
≤29 0 to 14 48
>14 24
>30 0 to 7 48
>7 24
Administer IV over 60 minutes

Flucytosine 12.5 to 37.5 mg/kg/dose q 6 hours PO Antifungal for Candida, Cryptococcus.

Increase dosing interval if renal
dysfunction is present.
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 Prevention of progressive hearing loss

Treat for a minimum of 6 weeks if possible and lessening of developmental delays in
Decrease dose by ½ for neutropenia (<500 symptomatic congenital CMV.
cells/mm3). Discontinue therapy if
neutropenia does not resolve after dose
reduction.
Administer over 60 minutes

Gentamicin* Give IV or IM Gram negative aerobic bacilli;

PMA Postnatal Dose Interval Usually used in combination with a beta-
(weeks) (days) (mg/kg) (hrs) lactam antibiotic. Administer as a
≤29 0 to 7 5 48 separate infusion from penicillin-
8 to 28 4 36 containing compounds.
≥29 4 24 Ototoxic effects synergistic with lasix.
30 to 0 to 7 4.5 36 Need to monitor serum levels:
34 ≥8 4 24 Trough: < 2, ideal 0.5 to 1.0; Peak: –5-
≥35 ALL 4 24 12 mg/L
Administer IV over 30 minutes For high trough levels, increasing dosing
interval to next higher level is usually
sufficient - always recheck levels again
after adjusting dosage/interval

Imipenem/Cilastatin 20-25 mg/kg/dose q12 hrs IV Non-CNS infections caused by

Administer over 30 minutes Enterobacteriaceae and anaerobes
resistant to other antibiotics. Seizures
common with meningitis and severe
renal dysfunction.

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

divided BID
Prophylaxis: 10 mg/kg PO qd
 Lamivudine 2 mg/kg/dose q 12 hours PO for 1 week Prevention of mother-to-child HIV
following birth transmission when no other therapy
Used in combination with zidovudine. during pregnancy.

Linezolid 10 mg/kg/dose q8 hours PO or IV Gram-positive organisms, incl. MRSA,

Preterm and < 1 week give q12 hours. refractory to vancomycin and other
Administer IV over 30 minutes. antibiotics. Not used for empiric
therapy.

Meropenem Sepsis: 20 mg/kg/dose IV Multidrug-resistant gram-negative,

Gest Age Postnatal Interval gram-positive, and anaerobic organisms.
(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

Methicillin 25 - 50 mg/kg/dose IV or IM Penicillinase-producing Staphylococcus

< 2 kg: < 7 d: q12 h; > 7 d: q 8 h aureus. Use the higher doses for
> 2 kg: < 7 d: q 8 h; > 7 d: q 6 h meningitis

Metronidazole Loading dose: 15 mg/kg IV/PO Anaerobic infections; begin maintenance

Maintenance dose: 7.5 mg/kg IV/PO dose 48 h after load in preterm infants &
PMA Postnatal Interval after 24 h in term infants.
(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

Mezlocillin 50 - 100 mg/kg/dose IV / IM Pseudomonas, Group B Strep, most

See Methicillin for dosing schedule Klebsiella pneumoniae and Serratia
marcescens

Mupirocin Apply small amount topically to affected MRSA topical infections. Do not apply
area q8 hours for 5-14 days. to the eye. May cover with gauze.

Nafcillin Usual: 25 mg/kg/dose IV Penicillinase-producing Staphylococcus

Meningitis: 50 mg/kg/dose IV aureus. Use nafcillin for renal
See Table 3 for dosing interval dysfunction pts.
Administer IV over 15 minutes

Nevirapine 2 mg/kg PO once at 48 to 72 hours of age. Used ONLY in combination with

If mother did not receive intrapartum zidovudine in treatment of neonates born
single-dose nevirapine, administer 2 mg/kg to HIV-infected women who had no
as soon as possible after birth. therapy during pregnancy.

Nystatin Preterm: 0.5 mL PO q6 hours Mucocutaneous candida infections.

 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.
Oxacillin 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
Penicillins See Table 3 for dosing interval
§ Pen G: Meningitis 75,000 - 100,000 IU/kg/dose IV or IM
Administer IV over 30 minutes
§ Pen G: Sepsis 25,000 - 50,000 IU/kg/dose IV or IM
Administer IV over 15 minutes
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
§ Benzathine 50,000 U/kg IM q wk x 3 doses
§ Procaine 50,000 units/kg q day, IM only
Piperacillin 50 to 100 mg/kg/dose IV or IM
See Table 3 for dosing interval
Administer IV over 30 minutes
Piperacillin-Tazobactam 50 to 100 mg/kg/dose IV or IM
(Zosyn) See Table 3 for dosing interval
Administer IV over 30 minutes
Ribavirin Dilute 6 gm in 300 ml sterile water.
Administer by aerosol over 12 - 18 hr
daily for 3 - 7 days
Rifampin PO: 10 -20 mg/kg q24 hr.
IV: 5 - 10 mg/kg q 12 hr
Administer IV over 30 minutes
Prophylaxis against invasive fungal
infections in VLBW infants. Do not
need if using fluconazole.
Penicillinase-producing Staphylococcus
Aureus. Interstitial nephritis.
Non-producing Penicillinase organisms
See Methicillin for dosing schedule
Treatment of susceptible organisms:
streptococci , cong. syphilis, gonococci
Syphilis (No clinical findings and only if
follow-up cannot be ensured)
Syphilis > 1 yr. in mother
Syphilis
Gram-positive, gram-negative, anaerobic
incl. Pseudomonas and Group B Strep.
Gram-positive, gram-negative, anaerobic
incl. Pseudomonas and Group B Strep.
Non-CNS infections.
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 child-
bearing age should not administer.
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.
Ticarcillin -Clavulanate 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

Tobramycin* 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

Trimethoprim- Prophylaxis: 2 mg/kg qHS PO UTI caused by E.coli, Klebsiella,

Sulfamethoxazole Treatment: 4 mg/kg q12 hours PO Enterobacter, Proteus
(Bactrim) Contraindicated < 2 months

Valganciclovir 16 mg/kg/dose PO q12 hours. Neutropenia common.

Treat for a minimum of 6 weeks. Prodrug If ANC<500 hold until >750
of ganciclovir. If ANC<750, reduce dose by 50%
If ANC<500 again, discontinue.

Vancomycin* 10-15 mg/kg/dose IV Methicillin-resistant staphylococci (e.g.,

PMA Postnatal Interval S aureus and S epidermidis) and
(weeks) (days) (hours) penicillin-resistant pneumococci. Note:
≤29 0 to 14 18 Red man syndrome results from rapid IV
>14 12 infusion.
30 to 36 0 to 14 12 Need to monitor serum levels
>14 8 Trough: 5-10 mg/L; Peak: 25 - 40 mg/L
37 to 44 0 to 7 12 Give 15 mg/kg/dose if CNS infection
>7 8
≥45 ALL 6
Administer IV over 90 minutes

Zidovudine IV: 1.5 mg/kg/dose over 60 minutes Treatment of HIV infection in

PO: 2 mg/kg/dose. combination with other antiretroviral
Do not give IM agents.
Begin treatment 6-12 hours after birth and Initiation of therapy after age 2 days is
continue for 6 weeks. 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 Table 3: Dosing Interval Chart

Gest. age Postnatal age Interval (q) PMA Postnatal Interval
< 29 wk 0 to 28 d 12 hr (weeks) (days) (hours)
> 28 d 8 hr ≤29 0 to 28 12
30 to 36 wk 0 to 14 d 12 hr >28 8
> 14 d 8 hr 30 to 36 0 to 14 12
≥37 wk 0 to 7 d 12 hr >14 8
>7d 8 hr 37 to 44 0 to 7 12
>7 8
≥45 ALL 6
Table 4: Usual Therapeutic Range
PEAK (µg/ml) TROUGH (µg/ml)
Gentamicin 5-12 0.5-1.0
Tobramycin 5-12 0.5-1.0
Kanamycin 20-25 5-10
Amikacin 20-30 2-5
Vancomycin 25-40 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.