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Empiric antimicrobial regimens for febrile young infants younger than 90 days of age without focal infections*

Empiric antimicrobial regimens for febrile young infants younger than 90 days of age without focal infections*
Age Common pathogens Empiric treatment
Neonate (≤28 days)

Common: Group B Streptococcus, E. coli

Less common: Listeria monocytogenes, Enterococcus, S. aureus, other Gram negative organisms, HSV
  • Ampicillin
  • and
  • ceftazidime or cefepime or cefotaxime (if available) or gentamicin
  • Add acyclovir when indicatedΔ
  • Add vancomycin when indicated◊
Infant (29 to 60 days)

Common: Group B Streptococcus, E. coli, S. pneumoniae, H. influenzae, N. meningitidis, S. aureus

Less common: Enterococcus, Listeria monocytogenes, Pseudomonas sp., other Gram negative organisms
  • Ceftriaxone or cefotaxime (if available)
  • Add ampicillin, when coverage for Enterococcus or Listeria monocytogenes infection is indicated or when meningitis is suspected
  • Add vancomycin, when indicated◊
  • Add gentamicin, when broader coverage for Gram negative pathogens is indicated
  • Add acyclovir when indicatedΔ
Infant (61 to 90 days)

Common: S. pneumoniae, H. influenzae, N. meningitidis

Less common: Group B Streptococcus, E. coli, S. aureus, Enterococcus, Listeria monocytogenes, Pseudomonas sp., other Gram negative organisms
  • Ceftriaxone or cefotaxime (if available)
  • Add vancomycin when indicated◊

HSV: herpes simplex virus.

* Broad-spectrum coverage is prudent until an organism is identified. For specific drug dosing, refer to drug monographs available by searching UpToDate, or while in an UpToDate topic, clicking on the drug name. Refer to UpToDate topics on management of febrile infants younger than 90 days of age.

¶ The choice of regimen should be based on local susceptibility patterns of E. coli and likelihood of L. monocytogenes infection or Enterococcus infection. Per the American Academy of Pediatrics Clinical Practice Guidelines, selected well-appearing neonates 22 to 28 days old with normal inflammatory markers may be eligible for intramuscular ceftriaxone and discharge home to reliable caregivers. However, the clinician must assure a follow-up visit within 12 to 24 hours for reevalution, review of culture results, and a repeated dose of ceftriaxone.

Δ Acyclovir is indicated in asymptomatic infants ≤28 days but at risk due to exposure (maternal active genital lesions); those with ill appearance, mucocutaneous vesicles, seizures, or cerebrospinal fluid pleocytosis; and in older infants with clinical findings of HSV infection.

◊ Vancomycin is warranted for coverage of methicillin-resistant S. aureus infection in regions with high prevalence (>10% of isolates) and for coverage of resistant S. pneumoniae in infants older than 28 days of age who are ill appearing or have findings of bacterial meningitis.
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