05 Nov 2026
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19.1 Neonatal Infections

Type of Infection First Line
(with Dosage and Duration)		 Alternative First Line
(with dosage and Duration)		 Comments
Possible serious bacterial infection, PSBI (community acquired) Amoxicillin • 20-40 mg/kg/dose PO* q8h Or Ampicillin • ≤ 34 weeks GA* and ≤ 7 days PNA*: 50 mg/kg/dose IV q12h • ≤ 34 weeks GA and ≥8 to ≤28 days PNA: 75 mg/kg/dose IV q12h • >34 weeks GA and ≤ 28 days PNA: 50 mg/kg/dose IV q8h) AND Gentamicin • < 37 weeks PMA*: 5 mg/kg/dose IV q48h • 37 to < 40 weeks PMA: 5 mg/kg/dose IV q36h • ≥ 40 weeks PMA: 5 mg/kg/dose IV q24h Duration of treatment: • If culture-negative: 5- 7 days • If culture positive: 7- 14 days In case of meningitis: Ampicillin (dose as mentioned in left- hand side column) AND Cefotaxime • < 1-week PNA: 50 mg/kg/dose IV q 12h • 1-4 weeks PNA: 50 mg/kg/dose IV q8h • > 4 weeks PNA: 37.5 mg/kg/dose IV q6h Duration of treatment: • 21 days Consider PSBI if any one of the following signs is present: • Not able to feed since birth or stopped feeding well (confirmed by observation) • No movement or movement only on stimulation • Convulsions • Fast breathing (60 breaths per minute or more) in infants younger than 7 days of age • Severe chest in-drawing • Fever (≥ 38.0 oC) • Low body temperature (< 35.5 °C) Signs are nonspecific.
Possible serious bacterial infection (possible hospital acquired/community with high AMR, e.g., > 10% prevalence of ESBL), without meningitis Amikacin • < 30 weeks PMA and ≤7 days PNA: 15 mg/kg/dose over 30 minutes slow IV q48 h • < 30 weeks PMA and >7 days PNA or 30-36 weeks PMA and ≤ 7 days PNA: 15 mg/kg/dose over 30 minutes slow IV q36 h • 30-36 weeks PMA and >7 days PNA or ≥37 weeks PMA: 15 mg/kg/dose over 30 minutes slow IV q24 h AND (Piperacillin- tazobactam • ≤ 30 weeks PMA: 100 mg/kg/dose IV infusion over one hour q8h • >30 and ≤ 35 weeks PMA: 80 mg/kg/dose IV infusion over one- hour q6h • >35 and ≤ 49 weeks PMA: 80 mg/kg/dose IV infusion over one hour q4h Or Ciprofloxacin (may be avoided in neonates because of concerns of arthropathy) 10 mg/kg/dose IV q12 h) Duration of treatment: • If culture-negative: 5- 7 days If culture positive: 7-14 days Meropenem • <32 weeks GA and <14 days PNA: 20 mg/kg/dose IV q 12h • < 32 weeks GA and ≥ 14 days PNA: 20 mg/kg/dose IV q 8h • ≥ 32 weeks GA: 30 mg/kg/dose IV q8h In case of high rates of MRSA, ADD Teicoplanin • 10 mg/kg/dose IV q 12 h for 3 doses, then 10mg/kg/day IV/IM q 24 h Duration of treatment: • If culture- negative: 5-7 days • If culture positive: 7-14 days • If treating for possible MRSA, prefer 14 days Do not mix amikacin with Piperacillin-tazobactam due to Y – site incompatibilities. Since in vitro response to teicoplanin is much better and being less nephrotoxic, it may replace vancomycin which requires mandatory TDM’s
Meningitis Cefotaxime (dose as mentioned above) Duration of treatment: • 21 days Ampicillin (dose as mentioned above) AND Cefepime • < 36 weeks GA and < 30 days PNA: 30-50 mg/kg/dose IV q 12 h • ≥ 36 weeks GA and < 30 days PNA: 50 mg/kg/dose IV q 12h If ESBL prevalence is > 10%: Meropenem (dose as mentioned above) Duration of treatment: • 21 days May avoid aminoglycosides for meningitis due to poor CSF penetration
Conjunctivitis Bacterial: Tobramycin or gentamicin • Ophthalmic drops— q6-8h Duration of treatment: • 7 days Viral: Mild to moderate: No antiviral agent. Only supportive care. Severe: HSV conjunctivitis: Acyclovir • 20 mg/kg/dose IV q8h AND Trifluridine • 1% topical eyedrops q 2-3h Or Ganciclovir gel • 0.15% topical q2-3h Adenovirus conjunctivitis: No specific antiviral agent CMV conjunctivitis (extremely rare): • treat underlying systemic disease with IV ganciclovir Duration of treatment: • 14 days • 21 days if disseminated or CNS HSV disease
Superficial infections (omphalitis, superficial abscesses) Mild Cloxacillin • 25-50 mg/kg/dose PO* q6h Duration of treatment: • 5-7 days Severe Cloxacillin • ≤7 days of PNA and <2 kg: 25 mg/kg/dose IV q12h • ≤7 days of PNA and <2 kg: 25 mg/kg/dose IV q8h • 7-28 days PNA and < 2 kg: 25 mg/kg/dose IV q8h • 7-28 days PNA and > 2 kg: 25 mg/kg/dose IV q6h AND Gentamicin (Dose as mentioned above) Duration of treatment: • 7-10 days Clindamycin • <4 weeks PNA: 15-20 mg/kg/day IV 6- 8 hrly No dosing recommendation for preterm neonates AND Gentamicin (Dose as mentioned above) Duration of treatment: 7-10 days
Tetanus Neonatorum Tetanus Immunoglobulin • 6,000 IU* IM* once AND Metronidazole • < 34 weeks PMA: 15 mg/kg LD* followed by 7.5 mg/kg/dose q12h • 34 to 40 weeks PMA: 15 mg/kg LD followed by 7.5 mg/kg/dose q8h • > 40 weeks PMA: 15 mg/kg LD followed by 7.5 mg/kg/dose q6h Alternative to metronidazole is penicillin G (less preferred as it may worsen spasms) • 50,000 IU/kg/dose IV q 6-8h India was declared free of maternal and neonatal tetanus on 15th May, 2015.
Oro-cutaneous candidiasis Localised Cutaneous Term and late preterm infants Clotrimazole • 1% ointment locally q 8-12h Oral • 2% nystatin suspension after every feed Or • 1% clotrimazole suspension after every feed Duration of treatment: 7-10 days and 48 hours after lesions have cleared Preterm infants (especially extremely preterm) Fluconazole • 12 mg/kg/dose q24 h Or Amphotericin B • 1 mg/kg/dose q24h Duration of treatment: • 14-21 days Widespread (burn like) or cutaneous candidiasis [term or preterm] Fluconazole (dose mentioned in the left-hand side column) Or Amphotericin B (dose mentioned in the left-hand side column)
Disseminated or CNS HSV infection Acyclovir • 20 mg/kg/dose IV q 8 h AND Post treatment for CNS disease, suppressive regimen • Acyclovir 300 mg/m2/dose PO q8h Duration of treatment: • for the IV regimen: 21 days • for the oral suppressive therapy post-treatment: 6 months Went to suspect? HSV CNS infection: focal neurological deficits, profound encephalopathy and CSF picture which is not typical of bacterial meningitis Disseminated HSV infection: severe sepsis-like syndrome with severe liver dysfunction (markedly raised aminotransferases)

For common etiological agents of Neonatal Infections, see Annexure B.19.1

Additional Information

*PO-per oral; GA- gestational age; PMA-postmenstrual age; PNA-postnatal age; IM-intramuscular; IU- international units; LD-loading dose.

  1. For prevention of Neonatal Infections, the following points are recommended:

    • Use basic hygiene and cleanliness during delivery

    • Special attention to cord and eye care

    • Exclusive breast feeding

    • Strict procedures for hand-washing for all staff and family members, before and after handling babies

    • Avoid incubators (wherever possible encourage 'Kangaroo Care')

    • Remove IV line when no longer needed

    • Avoid unnecessary blood transfusions

    • Strict sterility for all procedures such as injections

    • Biomarkers (C-reactive protein, procalcitonin,) may be used adjunctively in the diagnosis and management of neonatal infection.

  2. Note on antifungal prophylaxis in VLBW babies:

    • Fluconazole 3 or 6 mg/kg 2 times per week iv or orally in ALL neonates <1000 g in NICUs with high frequency of IC

    • Fluconazole 3 or 6 mg/kg 2 times per week iv or orally in NICUs with a lower incidence of IC (i.e. <2%) for neonates: (a)with birth weight <1000 g,(b)who have risk factors (i.e. central venous catheters, third-generation cephalosporins and carbapenems) for the development of IC (B-II)

    • *Decision for prophylaxis is on an individual basis

References

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2. Web Annex B. World Health Organization Model List of Essential Medicines for Children - 9th List, 2023. In: The selection and use of essential medicines 2023: Executive summary of the report of the 24th WHO Expert Committee on the Selection and Use of Essential Medicines, 24 - 28 April 2023. Geneva: World Health Organization; 2023 (WHO/MHP/HPS/EML/2023.03). Licence: CC BY-NC-SA 3.0 IGO
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