Empirical antibiotics and when to stop

OSCE stationVivaEarly-onset sepsis

A viva on first-line antibiotics for early-onset sepsis, the case against routine broad-spectrum cover, and the rules for stopping.

Questions

1. What empirical regimen do the AAP and NICE recommend?

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   • AAP: ampicillin and gentamicin.
   • NICE: intravenous benzylpenicillin sodium with gentamicin, unless local resistance data indicate another antibiotic.

2. Why does the AAP not recommend routine broader-spectrum cover, and when might it be added?

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   • Two-thirds of E. coli EOS isolates are ampicillin-resistant, but most remain gentamicin-sensitive, so routine broader-spectrum use is typically not justified and may be harmful.
   • About 7% of E. coli cases (1.7% of all EOS) were resistant to both.
   • Broader agents may be indicated in critically ill term infants until cultures are known, and in severely ill, high-risk preterm infants, particularly after prolonged antepartum maternal antibiotics.

3. What are the NICE starting doses, and when is the second gentamicin dose usually given?

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   • Benzylpenicillin 25 mg/kg every 12 hours (consider every 8 hours if very ill); gentamicin starting dose 5 mg/kg.
   • A second gentamicin dose, if given, is usually 36 hours after the first; shorter if the baby is very ill or the culture shows a Gram-negative infection.

4. At 36 hours the culture is negative. Under NICE, what must be true for antibiotics to be stopped?

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   • The blood culture is negative.
   • The initial clinical suspicion of infection was not strong.
   • The clinical condition is reassuring, with no clinical indicators of possible infection.
   • CRP levels and trends are reassuring.
   • If treatment continues beyond 36 hours despite negative cultures, review the need at least every 24 hours.

Based on: American Academy of Pediatrics clinical reports on early-onset sepsis (Pediatrics, 2018); NICE guideline NG195, Neonatal infection: antibiotics for prevention and treatment (2021, last updated May 2026).