use of antimicrobials in neonatal practice

1. DR AFROZA ISLAM SHUMA
DR YASHU SAH
Resident ,year -3
Neonatology
BSMMU.

2. Case Scenario-1
• D/O Luna, inborn, was admitted to NICU, BSMMU at 1
hour of age with the complaints of Prematurity(34wks)
LBW(1700gm). Mother had history of PROM for 2 days
before delivery. On examination baby was pink in room
air, with good reflex & activity, SPO2 -95%, normothermic,
euglycemic & well perfused, vitals-stable, systemic
examination revealed normal findings.
• What is the choice of antibiotic for this patient?

3. Case Scenario-2
S/O Rima, inborn, was admitted to NICU of BSMMU at
30min of age with the complaints of prematurity (33wks),
VLBW(1300gm) and respiratory distress soon after birth. Baby
was managed with IV fluid, inj ampicillin and gentamycin and
CPAP care. At 82hrs of PNA baby developed lethargy . On
examination baby was pink in room air, with poor reflex &
activity, SPO2-95%, normothermic, euglycemic & well
perfused, other vitals-normal and systemic examination-
normal findings. Sepsis screen was positive and blood C/S-
showed no growth of organism.
• Now what is the next choice of antibiotic for this patient?

4. Case Scenario-3
• S/O Sumaiya, outborn, admitted into NICU on 21 days of
age with diagnosis of preterm(30wk) , VLBW(1230g), RDS
(resolved) with LONS. On admission baby was Pink with
2l/min O2, with good reflex & activity, vitals were stable,
SPO2-95% with 2l /min O2, euglycemic & well perfused.
Baby was managed with IV fluid along with OG feeding, inj
cefepime and colistin. In previous hospital baby was
treated with inj ceftazidime and amikacin (day 1-5) and inj
meropenem and vancomycin (day 6-16).

5. • Then during hospital course in BSMMU baby developed
culture positive LONS 3 times on PNA Day-24
Acinetobacter +ve (sensitive to netilmycin and colistin), on
D-28 Klebsiella +ve (sensitive to colistin) & D-31, Klebsiella
+ve (sensitive to colistin and chloramphenicol).He was
treated with Piperacillin and Tazobactum + Linezolid - D26
– D29 = 3 days ,Colistin + Netilmicin - D30- D37 = 7 days
Colistin + Ciprofloxacin- D38= 10days.

6. Multiple culture
positive organism
Antibiotic
resistance
ANTIBIOTICS !!!!!
Our challenges

7. Use of Antimicrobials in
Neonatal Practice

8. Contents
• Factor predisposing to the development of neonatal
infection
• Why antimicrobials are required?
• Factors to be considered before prescribing antimicrobials
• Common antimicrobials used in Neonatal Practice
• Current scenario- Prevalence of organism ,Spectrum of
antibiotic coverage and sensitivity pattern
• Common newborn infections
• Measures to be taken-Rational use of antimicrobials
• guideline of antimicrobials
• Take home messages

9. Introduction
• Prevalence of infection in newborn is high than any other
period of life due to-
- Physiological & immune system immaturity
- Survival of preterm babies has been increased
• Antimicrobials use in the NICU is 10 times more frequent than
in the rest of the hospital beds.
• Virtually all extremely low birth weight infants receive
antimicrobials and for all other birth weight groups admitted
to the NICU the vast majority are treated with antimicrobials.

10. Factor predisposing to the development neonatal
infection
• Newborn are less capable of responding to infection due to
immunologic deficiencies.
• Infectious agents can be transmitted from mothers to fetus
or newborn by diverse modes.
• Infections are often undiagnosed because mother was
either asymptomatic or had non-specific sign symptom.
• Clinical manifestation are nonspecific including subclinical
infection.

11. • Coexisting condition complicate the diagnosis and
management.
• A wide variety of etiological agent e.g bacteria, virus,
fungi, protozoa etc.
• Premature , VLBW babies need prolong NICU stay which
increase risk for acquired infection.

12. Why antimicrobials are required ?
• Suppressed immune system of neonates leads to higher
incidence of infection
• Invasive procedure
• Surgical procedure
• Use of parenteral fluid
• Use of catheters (UAC, UVC, ETT)
Reference: Meyer E et al. Intensive Care Med.2006; 30:1089-96

13. Antibiotic Prescription is Common in NICU
• Antibiotics are greatly over prescribed in the NICU.
• In a point prevalence study of 29 NICUs, 47% of 827
infants were receiving at least one antibiotic on the day
of the survey.
Reference: Grohskopf L et al.Pediatr Infect Dis J. 2005;24:766-773

14. Effect of antibiotics on the neonate
• Newborn: sterile gut.
• Normal flora: early days of life.
• Antibiotics : delay in microflora colonisation with most
anaerobes, importantly Bifidobacterium and Lactobacillus.
• Antibiotics also limit the number of bacterial species in the
normal flora.
• An inverse dose- response between the duration of
antibiotics and the number of species in the flora.
• Bacterial overgrowth of other species
• A major role in restricting the diversity and the volume of the
normal flora thus reducing protection from invading
pathogens

15. Factors to be considered before prescribing
antimicrobials
• Dose and frequency : as per body weight ,gestation and
post natal age.
• Route :oral and IM unreliable, so I/V is considered.
• Coverage of both Gram positive and negative- choose
based on local bacterial C/S.
• Combination of drugs should use for synergistic effect.

16. • Adjust dose and frequency -if hepatic and renal
impairment.
• Co-morbidities e.g.- congenital anomalies, AKI .
• Choice of empirical antibiotics- dependent on: Protocols,
local previous C/S.
• Avoid reserve drugs like Vancomycin, ciprofloxacin,
Teicoplanin etc
• The duration of therapy is dependent upon culture results
and clinical course.
• Downgrade antibiotics as per C/S report

17. ● Drugs-
 Interaction- ceftriaxone is not recommended for use with
hyper-bilirubinemia and hyper-albuminemia as it
displace bilirubin from albumin binding site, PHB like
enzyme inducer.
 Storage- temp, duration.
 Administration- proper precaution e.g.- amphotrericin B,
vancomycin.
 Drugs manufacturing, e.g- expired date.

18. Precautions to be taken
 Aminoglycosides:
• Nephrotoxic- 8- 26% developed mild reversible renal
impairment if use > 7-10 days
• Increased toxicity if used with other nephrotoxic drugs
e.g.- frusemide, vancomycin. Monitor renal function and
trough level.
• Ototoxic – gentamycin causes vestibular and amikacin
causes auditory damage
• Never be placed with same infusion fluid if used with
penicillin – because on prolonged contact, positively
charged aminoglycosides form an inactive complex with
negatively charged penicillin.

19. Precautions to be taken
• Vancomycin :
• Nephrotoxic & ototoxic- use with caution.
• Rapid infusion- rash and hypotension ( Red man
syndrome), so infuse slowly over 1 hr.
• Phlebitis - extremely irritant to the tissues. Should
decrease rate and dilute appropriately.
• Linezolid :
• expensive drug, should reserve. used in MRSA, VRE.
• Monitor BP when co administer with dopamin,
dobutamine

20. Avoid redundant coverage
Category of use Examples
Double anaerobic coverage Meropenem and
metronidazole
Double gram positive
coverage
Ampicillin and vancomycin

21. Oral Antibiotics in the Management of Serious
Neonatal Bacterial Infections in Developing
Country Communities
They reviewed the evidence for treatment of neonatal
infections in developing countries with oral antibiotics.
• this strategy has resulted in substantial reductions in
neonatal mortality .
• Parenteral therapy should be used for treatment of
serious neonatal infections whenever possible. In
settings in which this is not possible, oral antibiotic
therapy is superior to no antibiotic therapy.
(Pediatr Infect Dis J 2009;28: S31–S36)

22. Simplified Antibiotic Treatment (SAT)
• Safety and Efficacy of Simplified Antibiotic Regimens for
Outpatient Treatment (SAT) of Suspected Severe
Infections in Neonates and Young Infants (Bangladesh)
• The Simplified Antibiotic Treatment (a randomized
controlled) Trial in Bangladesh provided evidence that
simpler antibiotic regimens involving 2 days of injection
followed by oral antibiotics for treatment of clinically
severe infection in young infants are as efficacious as the
standard regimen involving 7 days of injectable
antibiotics, thus expanding treatment options for many
more infants who live in resource poor settings where
hospital care is not accessible. The treatment failure
rates (9.8%, 8.3%, and 8.1%), death any time before day
15 follow-up (1.5% to 1.8%), and relapse rates (<2%)
similar among all three treatment arms.

23. The Lancet Global Health , vol-3, p 279-87, May 2015

24. The Lancet Global Health , vol-3, p 279-87, May 2015,
The Pediatric Infectious Disease Journal Vol 32,Num
9,Supplement,Sep 2013

25. Common antimicrobials
used in Neonatal Practice

27. Classification and Sites Of Antibiotics Action

28. Choices of Antibiotic
Beta β-lactum antibiotics
Penicillin
 Natural (Benzylepenicillin, Phenoxymethylpenicillin)
 Methicillin/Flucloxacillin
 The Aminopenicillins
 Carboxypenicillin (Ticarcillin) and Ureidopenicillins
(piperacillin)
 Cephalosporins
 Monobactum
 Carbapenems

29. The Aminopenicillin
(Ampicillin)
Same spectrum of
activity as the natural
penicillins with
additional Gram
negative cover against
Enterobacteriaceae.
Ureidopenicillin
(Piperacillin)
These are particularly
active against Gram
negative organisms,
especially Pseudomonus ,
used with tazobactam( b-
lactamase inhibitor)

30. Use of Piperacillin-Tazobactum in NICU:
Evidences
• Piperacillin-tazobactam (PIP/TAZO) has been extensively
used in adults with nosocomial infections.
• PIP/TAZO may safely be used in neonate as an empiric
treatment for serious infections in hospital environments
where resistance to common first-line antimicrobials has
emerged.
• The change from ceftazidime to piperacillin/tazobactam is
associated with a decrease in the incidence of Klebsiella
sepsis.
References: Wolf MF, Simon A. Expert Opin Drug Metab Toxicol. 2009 Jan;5(1):57-69.
Fidel-Rimon O, Friedman S, Gradstein S. Acta Paediatr 2003 Oct;92(10):1205-7.

31. 4th generation Cephalosporin: Cefepime
Evidences of use in NICU
• Excellent broad spectrum activity. Have little anti-
anaerobic activity and none against Enterococcus
spp.
• Useful in critical pneumonia, soft and bone tissue
infection, UTI.
• It eradicates organisms which have shown
resistance to other β-lactum antibiotics.
• Monotherapy gives both the good clinical
response and an excellent microbiological
clearance.
Ref: Sukhbir Kaur Shahid. Clinical Medicine Review in Therapeutic.2010; 2: 1-10

32. Carbapenem
(Meropenem,Imipenem)
Broadest antibiotic
activity of β-lactum
antibiotics and include
activity against
anaerobes.
Glycopeptides
Vancomycin
Effective against MRSA and
resistant enterococci.
Only enters CSF in the
presence of inflammation.

33. Oxazolidinones: Linezolid
• Only oxazolidinone
currently available for
clinical use.
• Activity against Gram
positive organisms such as
MRSA, Vancomycin
resistant Enterococci
(VRE),penicillin resistant
Strepto pneumoniae(PRSP).

34. Use of Linezolid in NICU: Evidences
• Linezolid is promising agent for the treatment of mainly
resistant Gram positive infection after treatment failure.
• Effective for the treatment of pneumonia, skin and soft
tissue infection, CNS infection and osteoarticular infection.
• Linezolid is effective, well tolerated in neonatal age group.
• Safe and effective alternative to vancomycin in preterm
infants.
Ref: John Dotis et al. International Journal of Infectious Disease 14(2010)e638-e648.
G. Giannouli et al. Linezolid treatment of nosocomial resistant gram positive bacteria in neonates.
Kocher S. Int J Antimicrob Agent. 2010 Aug;36(2):106-10.

35. Aminoglycosides
Gentamicin
Very effective in Gram
negative sepsis and body
fluid infection, exerting
synergism with β- lactum
antibiotics.
Fluroquinolones
Ciprofloxacin
• Greater activity against
Gram negative organisms.
• Can be used against
respiratory pathogens in
an empirical manner.

36. Colistin
• Colistimethate intravenous administration appears to be
safe and efficacious for multidrug-resistant Gram-
negative infections in neonates, including preterm and
extremely low birth weight neonates.
• Aerosolized colistin was tolerable and safe, and it may be
an adjunctive treatment option for MDR gram-negative
bacterial VAP in neonates.
References: Celik IH, Oguz SS, Demirel G.Eur J Pediatr.2012 Feb;171(2):311-6.
Jajoo M, Kumar V, Jain M.Pediatr Infect dis J. 2011 Mar;30(3):218-21.

37. Common infections of
newborn and antimicrobials

38. Sepsis

39. Bacterial Etiology of Neonatal Sepsis
In developed country
• Early Onset Sepsis
– GBS and E coli
– Recently decrease in Gram
positive organisms (GBS) and
increase in Gram negative
organisms
• Late Onset Sepsis
– Coagulase Negative Staph
(CONS)
– GBS
– Staph Aureus
In developing country
• Gram negative organisms
– Klebsiella, Escherichia coli,
– Pseudomonas,
– Acinetobacer, Enterobacter,
Citrobacter.
• Gram positive less
common
– Staphylococcus Aureus
– Coagulase negative
staphylococci (CONS)
– Streptococcus pneumoniae,
– Streptococcus pyogenes

40. Empiric Antibiotic Therapy
• Treatment is most often begun before a definite causative
agent is identified. Cover both gram (+)ve and (-)ve organism.
• For EONS - Ampicillin and gentamicin.
• For suspected LONS - Ampicillin and gentamicin, cefotaxime
can be added only when there is a concern for meningitis.
• In nosocomial sepsis, flora of the NICU must be considered.
• For staphylococcal coverage - vancomycin plus an
aminoglycoside such as gentamicin or amikacin .

41. • About 70% of these isolates may not be covered by the
empiric regimen of ampicillin and gentamicin.
(Zaidi et al, international journal of pediatrics, 2011)
• Third-generation cephalosporins should be avoided.
• In the developed countries- CoNS is the predominant
nosocomial pathogen. They use vancomycin as empirical
therapy.
• The Cochrane review : study by Miall-Allen et al Timentin
(ticarcillin and clavulanic acid) monotherapy with a
combination of flucloxacillin and gentamicin in 28
neonates with suspected LOS. No difference in outcome
(mortality/treatment failure) between the two groups.

42. Empiric Antibiotic Therapy
• Therapy should be unit specific
• Determined by the prevalent spectrum of etiological
agents and their antibiotic sensitivity pattern
• Should be modified according to sensitivity reports
• Choice is dependent upon the probable source of
infection

43. Duration of therapy
• Mainly based on culture and sensitivity results,
clinical course, Serial lab investigation.
• Chowdhary et al. compared the effectiveness of 7-
day versus 14-day antibiotic therapy in 69 infants
with blood culture-proven bacterial sepsis.
• More treatment failures in 7-day group.
• Treatment failures occurred in subjects with
S.aureus infection receiving 7-day course.
Journal of Tropical Pediatrics Vol. 52, No. 6, 2014

44. Antibiotic use protocol NICU, BSMMU
Antibiotics
1st line Ampicillin+ Gentamicin
2nd line Ceftazidime + Amikacin
3rd line (reserve) Meropenem, Ciprofloxacin, Vancomycin,
Cefepime, Clarithromycin, Netilmicin,
Imipenem, Piperacillin-Tazobactam, Colistin
In case of
suspected
meningitis
Cefotaxim + Amikacin or Meropenem +
Amikacin

45. Management protocol of newborn, doctors handbook, BSMMU

46. Suggested Antibiotic Regimens
Organism Antibiotic Bacteremia Meningitis
GBS Ampicillin 10 d 14-21 d
E. coli Cefotaxim or ampicillin and
gentamicin
10-14 d 21 d
CONS Vancomycin 7 d 14 d
Klebsiella,
Serratia
Cefotaxime or meropnem and
gentamicin
10-14 d 21 d
Enterobacter,
Citrobacter
Cefepime or meropenem and
gentamicin
10-14 d 21 d
Enterococcus Ampicillin or vancomycin and
gentamicin
10 d 21 d
Listeria Ampicillin and gentamicin 10-14 d 14-21 d
Pseudomonus Ceftazidime or
piperacillin/tazobactum and
gentamicin
14 d 21 d
MRSA Vancomycin 10-14 d 21 d
Manual of Neonata Care by John P. Cloherty

47. Fungal Infections
• The overall incidence of fungal septicemia on neonatal
units is increasing because of both increased survival of
VLBW neonates and use of broad spectrum antibiotics.
• Transmission may be vertical ( from maternal to vaginal
infection/colonisation) or horizontal.
• 3rd most common cause of late-onset sepsis in NICU
(high risk)

49. Risk factor for fungal infection

50. Classification and Sites Of Antibiotics Action

51. Common Fungal Infection
 Oral candidiasis: common in breast fed infant with
ductal candidiasis with mothers breast.
• nystatin oral suspension-1ml every 6 hrly for 10-14 days
or fluconazole
 Candidal diaper dermatitis: 2% nystatin or 2% mionazole
ointment or 1% clotrimazol cream
 Systemic candidiasis:
• Amphotericin B 0.5 -1mg/kg/day for 7-14 days after
negative blood c/s or 3 wks if end organ affected. But
causes phlebitis, hypokalemia, hypomagnesemia,
hyperglycemia, nephrotoxicity. so given slowly over 2hrs.
• Or Fluconazole 6mg/kg/day or flurocytosine

52. Selective fluconazole prophylaxis in high‐risk babies to
reduce invasive fungal infection
Brian A McCrossan, Elaine McHenry, Fiona O'Neill, GraceOng, and David G Arch Dis
Child Fetal Neonatal Ed, v.92(6); Nov 2007
• Fluconazole 6 mg/kg for 3 weeks. Dose interval every 72
h during the first 2 weeks of life. Thereafter, dose interval
reduced to every 48 h until 3 weeks old when daily
fluconazole is given.
• 6/33 babies eligible for prophylaxis developed culture
proven Candida sepsis before compared with no (0/31)
babies after the guideline was implemented (p=0.03).
• Selective antifungal prophylaxis has reduced invasive
fungal sepsis.

53. Viral infection
• Most of this infection are acquired by vertical
transmission, but some are the result of cross infection
postnatally.
• Indication of antiviral therapy:
• HIV infection and AIDS
• Herpes viruses
• Varicella – zoster infection
• Enteroviruses
• Neonatal hepatitis e.g.- hepatitis B
• TORCH infection- congenital rubella, CMV, toxoplasmosis

55. Anti –viral Drugs
 Anti herpes virus agents-
used in- HSV-1,HSV-2, VZV, shingles
• acyclovir/ valacyclovir
• Famciclovir / Penciclovir
• Ganciclovir/ cidofovir
 Anti cytomegalovirus Agents - CMV
• Gancyclovir/ Valgancyclovir

56.  Antiretroviral Agents
• 1.Nucleoside Reverse Transcriptase inhibitors (NRTIs)-
Zidovudine, lamivudine, stavudine
• 2. Nonnucleoside Reverse Transcriptase inhibitors
( NNRTIs)-Nevirapine, Delavirdine, Efavirenz
• 3. Protease inhibitors-Indinavir, Ritonavir, Saquinavir
• Anti-Hepatitis Agents
• hepatitis B : Lamivudine, Adefovir and tenovir
• hepatitis C : interferon alpha and Ribavirin

57. Burden and Impact of Infection
• Globally, serious neonatal infections cause an estimated
36% of neonatal deaths .
• In settings with very high mortality, neonatal infections are
estimated to cause 40% to 50% of all neonatal deaths.
• Five to 30% of all neonatal infections are nosocomial
infection.
• Overall, 30% neonates clinically suspected to have late
onset sepsis have positive blood culture.
• Antibiotics in NICUs consume 30% of the budget in tertiary
care hospital.
Singh et al.2000; 117:1496-99
Gerbending G. Clin Updates in Infect Dis.2000;5:1-4
Singh S A et al.J Trop Pediatr. 2003; 49:235-9

58. Bangladesh Scenario
• In a rural setting
sepsis constituted 12% of
direct causes of neonatal
deaths
• A study in Dhaka slums
showed sepsis as a direct
cause of neonatal deaths in
20% cases
Ref:Chowdhury HR, Thompson S, Ali M, Alam N et al. J Health Popul Nutr.2010; 28(4):375-382, Khatun F, Rasheed S, Moran
AC et al. BMC Public Health 2012, 12:84, Liu L, Johnson HL, Cousens S et al. Lancet 2012;379:2151-6, CHERG/WHO/UNICEF
for distribution of causes of neonatal and under-five deaths (published in Liu et al, Lancet 2014)

59. BSMMU SCENARIO

60. • Results: Organisms were isolated in 124/ 559 (22.2%) of the
collected blood samples. LONS 113/124 (91.1%), remaining
were early onset sepsis (EOS).
• Acinetobacter (46%) was found to be the most common
organism in LONS followed by Klebsiella (37.9%) and E.Coli
(6.4%).
• Most of the organisms were resistant to 1st and 2nd line
antibiotics. Colistin exhibits the highest sensitivity (93.5%)
followed by Tazobactum- piperacillin (54.8%), and then
Ciprofloxacin (44.3%), Netilmicin (43.5%) and Imipenem
(41.9%).
Bacteriological profiles and antibiotic susceptibility
pattern in NICU (Oct 2014 - Dec 2017)

61. Changing pattern of antibiotic sensitivity of organism
for most commonly sensitive 5 antibiotics

62. Sepsis in BSMMU NICU
44%
36.80%
33.50%
31.4% 32%
20.40% 20.70%
23% 22.04%
18.50%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
2015 2016 2017 2018 2019 (upto
May)
Sepsis Culture+ve

63. Bacterial Etiology of Neonatal Sepsis
Acinetobacter
51%
Klebsiella
32%
Pseudomonas
11%
E.coli
2%
Staphylococcus
3%
Others
1%

64. Antibiotic sensitivity pattern of 2019
0%
20%
40%
60%
80%
100%
120%

66. Irrational use of antimicrobials
• Lack of skills and knowledge
• Inappropriate unethical promotion of medicines by
pharmaceutical companies & Profits from selling
medicines
• Unrestricted availability of medicines
• Unaffordable medicines
• Lack of coordinated national or institutional
pharmaceutical policy

67. Consequences of irrational use of
antimicrobials
• Emergence of antimicrobial resistance.
• Increase infection related mortality and morbidity.
• Increase rate of nosocomial and overall infection.
• Adverse drug reactions and medication errors.
• Economic burden.
• Eroded patient confidence.

68. Measures to be taken
• Rational use of antimicrobials:
• Rational use of medicines refers to the correct, proper
and appropriate use of medicines. Rational use requires
that patients receive the appropriate medicine, in the
proper dose, for an adequate period of time, and at the
lowest cost to them and their community. (WHO)

69. Antibiotic Policy
• Components of rational use of antibiotic.
• Problems with selecting appropriate antibiotic use.

70. Components of Rational Use of Antibiotic
1. Timely antibiotic management
2. Appropriate selection
3. Appropriate administration and de-escalation
4. Consultation with infectious disease specialist
5. Local data and evidences

71. 1. Timely antibiotic management
• Accurately identify patients who needs antibiotic
therapy
• Obtain culture prior therapy
• Administer antibiotic without delay
• Specify the duration of therapy

72. 2. Appropriate selection
• Make empiric choice based on local epidemiology.
• Do not give therapy with overlapping activity

73. 3. Appropriate administration and
de-escalation
• Give the right dose and interval
• Monitor for toxicity and adjust accordingly e.g-
aminoglycosides need renal dose adjustment
• Review culture results and adjust accordingly
• Stop therapy promptly if culture reports no growth.

74. 4. Availability of expertise
• Infectious disease specialist
• Implementation of antimicrobial stewardship

75. 5. Local Data and Evidences
• Assigned person to monitor antibiotic utilization, adverse
events related to antibiotic use, bacterial etiology and
their culture and sensitivity pattern.
• Set antibiotic policy according to changing pattern of
culture and sensitivity report
• Create local evidence
• Review the policy

77. Guidelines of antimicrobial therapy
• Exclude contaminant positive blood culture.
• Give antibiotic with a narrower spectrum or lower
cost.
• If possible, a single sensitive antibiotic must be used,
the exception being Pseudomonus.
• If baby worsened with sensitive antibiotic, select an
alternative.
• If the empirical antibiotics are resistant but the
neonate has improved clinically. Careful assessment
must be made.

78. Guidelines of antimicrobial therapy
• One must not continue with antibiotics with in vitro
resistance in case of Pseudomonus, Klebsiella and
MRSA; and in cases of CNS infection and deep seated
infection.
• If no antibiotic has been reported sensitive, therapy
must be changed to ‘moderately sensitive’ antibiotics
at higher permissible dose. Use a combination in
such cases.

79. Take Home Message !!
• Suspected sepsis- send sepsis screen and blood culture;
start 1st line I/V antibiotics without delay.
• Downgrade or upgrade antibiotics as per C/S report
• If no response within 48–72 hours of starting treatment,
repeat blood C/S and change antibiotic therapy with
appropriate choice and duration.
• Use antimicrobials judiciously.
• Monitoring for toxicity and adjust therapy e.g.- monitor
renal function.
• Review antibiotic policy every 6 month.