Low-dose vancomycin prophylaxis reduces coagulase-negative staphylococcal bacteraemia in very low birthweight infants

Antibiotics Before Removal of Percutaneously Inserted Central Venous Catheters Reduces Clinical Sepsis in Premature Infants

OBJECTIVES

Evaluate the incidence of postcatheter removal clinical sepsis when antibiotics were infused prior to the removal of percutaneously inserted central venous catheters (PICCs).

METHODS

A retrospective chart review of premature neonates (n = 196) weighing ≤1250 g at birth with 218 PICC line removals in the presence or absence of antibiotics at a tertiary level neonatal intensive care unit (NICU) between January 1, 2010, and May 31, 2012. Charts were reviewed looking for the presence of clinical sepsis defined as a sepsis workup including white blood cell count, differential, C-reactive protein, blood and/or cerebral spinal fluid (CSF), and urine cultures along with at least 48 hours of antibiotic therapy given within 72 hours after removal of a PICC line. Antibiotics were considered present at line removal if given within 12 hours before catheter removal either electively or at completion of a planned course.

RESULTS

When antibiotics were given within 12 hours before PICC line removal, only 2% of the line removal episodes (1/48) resulted in a neonate developing clinical sepsis versus 13% (21/165) when no antibiotics were given prior to removal (p = 0.03, Fisher's exact test). Despite the increased use of elective antibiotics with line removal, there was no increase in total antibiotic usage due to the overall decrease in episodes of clinical sepsis or changes in antibiogram susceptibility patterns.

CONCLUSIONS

There was an 11% absolute decrease and a 6-fold relative decrease in postcatheter removal clinical sepsis events in premature neonates who received antibiotics prior to PICC line removal.

Secular trends in antibiotic use among neonates: 2001-2008

BACKGROUND

Few data exist on time trends of antibiotic consumption among neonates.

OBJECTIVES

To assess secular trends in antibiotic consumption in the context of an antibiotic policy and the effect of antibiotic use on the development of antimicrobial resistance and outcome among neonates in a single center.

METHODS

We performed a prospective cohort study between 2001 and 2008 to monitor antibiotic consumption among neonates. In parallel, we initiated a policy to shorten antibiotic therapy for clinical sepsis and for infections caused by coagulase-negative staphylococci and to discontinue preemptive treatment when blood cultures were negative. Time trend analyses for antibiotic use and mortality were performed.

RESULTS

In total, 1096 of 4075 neonates (26.7%) received 1281 courses of antibiotic treatment. Overall, days of therapy were 360 per 1000 patient-days. Days of therapy per 1000 patient-days decreased yearly by 2.8% (P < 0.001). Antibiotic-days to treat infections decreased yearly by 6.5% (P = 0.01) while antibiotic-days for preemptive treatment increased by 3.4% per year (P = 0.03). Mean treatment duration for confirmed infections decreased by 2.9% per year (P < 0.001). No significant upward trend was observed for infection-associated mortality. Of 271 detected healthcare-associated infections, 156 (57.6%) were microbiologically documented. The most frequent pathogens were coagulase-negative staphylococci (48.5%) followed by Escherichia coli (13.5%) and enterococci (9.4%). Rates for extended-spectrum beta-lactamase-producing microorganisms and methicillin-resistant Staphylococcus aureus remained low.

CONCLUSIONS

Shortening antibiotic therapy and reducing preemptive treatment resulted in a moderate reduction of antibiotic use in the neonatal intensive care unit and did not increase mortality.

Routine antibiotic use in preterm neonates: a randomised controlled trial

The immature immune system of preterm neonates puts them at higher risk of neonatal sepsis. We conducted a part-blinded randomised controlled trial to compare the effect of routine antibiotic treatment on the incidence of clinical sepsis in preterm neonates. Preterm neonates without other risk factors for infection admitted in the first 12h of life were randomised to receive routine antibiotics or to a control group (no antibiotics unless clinically indicated). The primary outcome variable was the incidence of clinical sepsis. Secondary outcomes were the incidence of positive blood cultures, necrotising enterocolitis (NEC) stage II or III, or death, and the duration of hospital stay. The incidence of clinical sepsis was comparable in both groups (intervention 31.9%, control 25.4%; P=0.392). Mortality was equivalent in both groups. The control group had significantly more positive blood cultures (P=0.002). The incidence of NEC and the duration of hospital stay were comparable in both groups. In low risk preterm neonates we found no evidence that routine antibiotic use has a protective effect.

Vancomycin prophylaxis for late-onset sepsis in very low and extremely low birth weight neonates

LATE-ONSET SEPSIS AMONG very low birth weight (VLBW) and extremely low birth weight (ELBW) neonates is a troubling occurrence. The most recently published data from the National Nosocomial Infection Surveillance system documents 5.4 umbilical- and central line–related bloodstream infections (BSIs) per 1,000 catheter days in infants weighing between 1,001 and 1,500 g.1 For infants weighing 1,000 g or less, the rate is 9.1 infections per 1,000 catheter days. A variety of factors, including prematurity and related relative immunocompromise, altered skin integrity, and multiple invasive procedures, places VLBW and ELBW neonates at risk for infection. Tunneled central catheters or peripherally inserted central catheters (PICCs) clearly add to the risk of infection in these vulnerable patients. In a point prevalence survey of a network of 29 NICUs, researchers found that coagulase-negative Staphylococcus (CoNS) was the causative organism in nearly half (48.3 percent) of the documented bloodstream infections.2 Vancomycin prophylaxis is a potential strategy for the prevention of late-onset sepsis associated with CoNS. This column explores the efficacy and safety of this strategy.

Prophylactic systemic antibiotics to reduce morbidity and mortality in neonates with central venous catheters

BACKGROUND

The use of central venous catheters is recognised as a risk factor for nosocomial infection. Prophylactic antibiotics may be effective in preventing catheter-related blood stream infection in newborns but may also have the undesirable effect of promoting the emergence of resistant strains of micro-organisms.

OBJECTIVES

To determine the effect of prophylactic antibiotics on mortality and morbidity in neonates with central venous catheters.

SEARCH STRATEGY

Searches were done of the Cochrane Neonatal Review Group Specialised Register, MEDLINE from 1950 to April 2007, CINAHL from 1982 to April 2007, and the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 2 2007). Previous reviews (including cross references) were also searched.

SELECTION CRITERIA

Randomised controlled trials or quasi-randomised controlled trials of adequate quality in which either individual newborn infants or clusters of infants were randomised to receive prophylactic antibiotics (not including antifungals) versus placebo or no treatment. Infants must have had central venous catheters, been full term infants less than 28 days old or preterm infants up to 44 weeks (postmenstrual) corrected age.

DATA COLLECTION AND ANALYSIS

Criteria and methods used to assess the methodological quality of the trials: standard methods of the Cochrane Collaboration and its Neonatal Review Group were used. The review authors extracted data independently. Attempts were made to contact study investigators for additional information as required.

MAIN RESULTS

Three small studies have been included in this review. Prophylactic antibiotics in neonates with central venous catheters had no effect on overall mortality (typical RR 0.68, 95% confidence interval 0.31, 1.51). Prophylactic antibiotics in neonates with central venous catheters decreased the rate of proven bacterial sepsis (typical RR 0.38, 95% confidence interval 0.18, 0.82). Prophylactic antibiotics in neonates with central venous catheters decreased the rate of suspected or proven bacterial septicaemia (typical RR 0.40, 95% confidence interval 0.20, 0.78). No resistant organisms colonising infants were identified in any of the studies. No pooled data were available for other important outcome measures such as chronic lung disease or neurodevelopmental outcome.

AUTHORS' CONCLUSIONS

Prophylactic systemic antibiotics in neonates with a central venous catheter reduces the rate of proven or suspected septicaemia. However, this may not be clinically important in the face of no significant difference in overall mortality and the lack of data on long-term neurodevelopmental outcome. Furthermore, there is a lack of data pertaining to the potentially significant disadvantages of this approach such as the selection of resistant organisms. The routine use of prophylactic antibiotics in infants with central venous catheters in neonatal units cannot currently be recommended.

Use of Vancomycin-Containing Lock or Flush Solutions for Prevention of Bloodstream Infection Associated with Central Venous Access Devices: A Meta-Analysis of Prospective, Randomized Trials

BACKGROUND

Prolonged exposure to central venous access devices carries significant risk of device-associated bloodstream infection (BSI), which is associated with morbidity, added health care costs, and attributable mortality. We aimed to determine the efficacy of vancomycin-heparin lock or flush solution in preventing BSI in patients being treated with long-term central venous intravascular devices (IVDs).

METHODS

We collected data from January 1966 to January 2006 from multiple computerized databases and compiled reference lists of identified articles. We identified prospective, randomized controlled trials comparing a vancomycin-heparin lock or flush solution with heparin alone for prevention of BSI associated with long-term central venous IVDs. Using a standardized form, we abstracted data regarding study quality, patient characteristics, and incidence of BSI.

RESULTS

Seven randomized, controlled trials involving a total of 463 patients being treated with IVDs met the inclusion criteria; 5 studies were conducted among patients with cancer, 1 among a critically ill neonatal population, and 1 among patients with cancer or who required parenteral nutrition. We could not detect publication bias. The summary risk ratio with a vancomycin heparin-lock solution for IVD-associated BSI was 0.49 (95% confidence interval [CI], 0.26-0.95; P = .03). Results of the test for heterogeneity were statistically significant; however, when a single study was removed from the analysis, heterogeneity was no longer present. Use of vancomycin as a true lock solution--instilling it for a defined period, rather than simply flushing it directly through the device--conferred a much greater benefit, with a risk ratio of 0.34 (95% CI, 0.12-0.98; P = .04). The 2 studies that performed prospective surveillance cultures to identify colonization or infection by vancomycin-resistant organisms did not find an increased risk.

CONCLUSIONS

Use of a vancomycin lock solution in high-risk patient populations being treated with long-term central IVDs reduces the risk of BSI. The use of an anti-infective lock solution warrants consideration for patients who require central access but who are at high risk of BSI, such as patients with malignancy or low-birthweight neonates.

Effect of a closed drug-delivery system on the incidence of nosocomial and catheter-related bloodstream infections in infants

We conducted a prospective, cohort study at two affiliated level III neonatal intensive care units to evaluate the effect of a closed drug-delivery system on the incidence of nosocomial and catheter-related bloodstream infections (CRBSI) in infants. A total of 300 infants (n=150 at each site) were enrolled over a 4-year study period. There was no difference in the rate of CRBSI per 1000 catheter days between the two sites (16.2+/-39 vs. 8.9+/-24, P=0.054, 95% CI-14.8 to 0.13). Infants at site A (closed drug-delivery system) had a higher rate of infectious nosocomial respiratory complications per 100 hospital days than infants at site B (open delivery system) (1.1+/-2.2 vs. 0.5+/-1.5, P=0.009), however, there was no difference in the overall number of confirmed or suspected nosocomial infection events per patient between study sites. Logistic regression revealed that the number of additional peripheral catheters, gestational age and duration of parenteral nutrition all significantly contributed to the risk of developing one or more CRSBI. The closed drug-delivery system failed to reduce the incidence of CRBSI or overall rate of nosocomial infections in premature infants.

Colonization and molecular epidemiology of coagulase-negative Staphylococcal bacteremia in cancer patients: a pilot study

BACKGROUND

Controversy surrounds the source (skin vs mucosa) of coagulase-negative staphylococci (CoNS) bacteremia in cancer patients. Determining the source of this infection has clinical and epidemiologic implications.

OBJECTIVE

To determine the source(s) of CoNS bacteremia in cancer patients.

METHODS

Between November 1998 and October 2000, cultures of nasal and rectal mucosa and skin at central venous catheter (CVC) sites were obtained in 62 patients (66 episodes) with CoNS-positive blood culture(s). Bacteremia was classified as true, indeterminate, or unlikely on the basis of clinical and microbiologic findings. Molecular relatedness of strains isolated from the blood and from colonized sites of patients with true and those with unlikely bacteremia was examined using pulsed-field gel electrophoresis (PFGE).

RESULTS

CoNS colonization was present in 55 episodes (83%). The nasal mucosa was the most frequently colonized site (86%), followed by rectal mucosa (40%) and skin at site of CVC insertion (38%) (P < .001). Colonization at > or =1 site was common. True and unlikely bacteremia accounted for 11 and 10 episodes, respectively, with the remaining 45 episodes considered undetermined or had negative surveillance cultures. Among patients with true bacteremia, 6 mucosal isolates and only 1 skin isolate were related by PFGE to the blood isolate recovered from the same patient.

CONCLUSION

Mucosa is the most common site of CoNS colonization and is the likely source of CoNS bacteremia in cancer patients.

Mucosa or skin as source of coagulase-negative staphylococcal bacteraemia?

Nosocomial bacteraemia is associated with significant morbidity, mortality, and cost worldwide, and is most commonly caused by coagulase-negative staphylococci (CONS). Establishing the source of CONS bacteraemia is therefore important in the prevention and management of this infection. CONS infections are presumed to originate at the cutaneous sites of central venous catheters (CVCs), a belief that has led to prevention strategies that focus almost exclusively on the skin. However, mucosal colonisation by CONS is well established, suggesting that mucosal sites might be an important source of CONS bacteraemia. We review the published material that evaluates the source(s) of CONS. We included only studies that used a strict definition of CONS bacteraemia, evaluated skin and other potential sources of CONS, and studied the molecular association between CONS blood isolates and their potential sources. Three published reports fulfilled our criteria. In cancer patients with CONS or CONS bacteraemia, most of the colonising strains that had a molecular match with the strain recovered from the blood of the same patient were mucosal isolates; by contrast, no association was seen between CONS blood and skin isolates. Furthermore, in several patient populations evidence was reported of mucosal colonisation by CONS and in several reports experimental and clinical mucosal translocation of CONS with subsequent bacteraemia was documented. Together these data indicate that mucosal sites are an important source of CONS bacteraemia. Clinical strategies for the treatment of patients with a positive blood culture for CONS, the widespread use of antimicrobial-coated CVCs, and maximum barrier protection for CVC insertion should be reassessed, and strategies to decrease mucosal colonisation by CONS should be developed.

Vancomycin usage in central venous catheters in a neonatal intensive care unit

BACKGROUND

We previously reported that vancomycin in hyperalimentation solution reduces catheter-related infections in the neonatal intensive care unit. Since June 1993 vancomycin (25 microg/ml) was routinely added to central venous catheter solutions, primarily hyperalimentation solution. Because the prophylactic use of vancomycin could lead to the emergence of resistant organisms, the decision to discontinue this practice was made in April of 1999. The use of vancomycin was reserved for documented infections with vancomycin-susceptible organisms.

OBJECTIVE

To compare catheter longevity, rate of laboratory-confirmed blood stream infections and total vancomycin exposure between two 18-month periods before and after the cessation of prophylactic vancomycin use.

METHODS

Data were evaluated for every neonate in whom a percutaneous central venous catheter was placed.

RESULTS

There were 394 neonates enrolled. No statistically significant difference was identified between the two periods regarding the mean catheter days or number of catheters per patient. There was a higher rate of Gram-negative laboratory-confirmed blood stream infections during Period I in patients with percutaneous central venous catheters in place. There were more isolates of coagulase-negative staphylococci in Period II, resulting in more frequent vancomycin therapy institution and thus an overall increase in the amount of vancomycin used in that period

CONCLUSION

Discontinuing the use of prophylactic vancomycin resulted in exposure of fewer neonates to vancomycin but a higher total amount of vancomycin used. The impact of low dose widespread exposure to vancomycin vs. high dose limited exposure on the microbiologic flora in the neonatal intensive care unit should be further examined.

G-CSF and GM-CSF for treating or preventing neonatal infections

BACKGROUND

The colony stimulating factors (CSFs), granulocyte-macrophage colony stimulating factor (GM-CSF) and granulocyte colony stimulating factor (G-CSF), are naturally occurring cytokines that stimulate the production and antibacterial function of neutrophils and monocytes. Two strategies have been adopted for exploring whether CSFs can provide clinical benefit for preterm infants. The first has investigated their use as a treatment to improve outcome in established systemic infection, especially when complicated by a low neutrophil count. The alternative strategy has been to use CSFs prophylactically, to prevent sepsis prospectively through stimulation of neutrophil production and bactericidal function.

OBJECTIVES

To determine the efficacy and safety of the haemopoietic colony stimulating factors (G-CSF or GM-CSF) in newborn infants, when used for:a) treatment of suspected or proven systemic infection to reduce mortality, orb) prophylaxis, to prevent systemic infection in infants at high risk of nosocomial infection. To determine, in subgroup analysis, the influence of pre-existing or high risk of neutropenia on the outcome of therapy.

SEARCH STRATEGY

PubMed, EMBASE, MEDLINE and the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 2, 2003) were searched in April 2003 using the keywords: G-CSF, GM-CSF, infant newborn, with and without the limit Clinical Trial. In addition, reference lists of identified RCTs, meta-analyses and personal files were searched.

SELECTION CRITERIA

The criteria used to select studies for inclusion were:

DESIGN

RCT.

SUBJECTS

Newborn infants in intensive care.

INTERVENTIONS

G-CSF or GM-CSF given as treatment in conjunction with antibiotics for suspected or microbiologically proven systemic infection. G-CSF or GM-CSF given as prophylaxis with the aim of reducing the incidence of systemic infection.

OUTCOMES

Treatment studies reporting all cause mortality. Prophylaxis studies reporting subsequent incidence of sepsis and / or mortality.

DATA COLLECTION AND ANALYSIS

Relative risks (RR) and risk differences (RD) with 95% confidence intervals (CI) using the fixed effect model are reported. Number needed to treat (NNT) was calculated for the outcomes that showed a statistically significant reduction in RR.

MAIN RESULTS

Seven treatment studies of 257 infants with suspected systemic bacterial infection and three prophylaxis studies comprising 359 neonates are analysed. Treatment studies: There is no evidence that the addition of G-CSF or GM-CSF to antibiotic therapy in preterm infants with suspected systemic infection reduces immediate all cause mortality. No significant survival advantage was seen at 14 days from the start of therapy [typical RR 0.71 (95% CI 0.38,1.33); typical RD -0.05 (95% CI -0.14, 0.04)]. However all seven of the treatment studies were small, the largest recruiting only 60 infants. The subgroup analysis of 97 infants from three treatment studies who, in addition to systemic infection, had clinically significant neutropenia (< 1.7 x 10(9)/l) at trial entry, does show a significant reduction in mortality by day 14 [RR 0.34 (95% CI 0.12, 0.92); RD -0.18 (95% CI -0.33, -0.03); NNT 6 (95% CI 3-33)]. Prophylaxis studies have not demonstrated a significant reduction in mortality in neonates receiving GM-CSF [RR 0.59 (95% CI 0.24,1.44); RD -0.03 (95% CI -0.08,0.02)]. The identification of sepsis as the primary outcome of prophylaxis studies has been hampered by inadequately stringent definitions of systemic infection. However, data from one study suggest that prophylactic GM-CSF may provide protection against infection when given to preterm infants who are neutropenic or at high risk of developing postnatal neutropenia.

REVIEWER'S CONCLUSIONS

There is currently insufficient evidence to support the introduction of either G-CSF or GM-CSF into neonatal practice, either as treatment of established systemic infection to reduce resulting mortality, or as prophylaxis to prevent systemic infection in high risk neonates. No toxicity of CSF use was reported in any systemic infection to reduce resulting mortality, or as prophylaxis to prevent systemic infection in high risk neonates. No toxicity of CSF use was reported in any study included in this review. The limited data suggesting that CSF treatment may reduce mortality when systemic infection is accompanied by severe neutropenia should be investigated further in adequately powered trials which recruit sufficient infants infected with organisms associated with a significant mortality risk.

Vancomycin and gentamicin in neonates: hindsight, current controversies, and forethought

The use of both vancomycin and gentamicin in the treatment of suspected or documented neonatal infections, while routine, is a challenge for bedside and advanced practice nurses caring for neonates in intensive care units. A review of the background information surrounding neonatal infections as well as the history, intended use, and the pharmacokinetic and pharmacodynamic properties of vancomycin and gentamicin is presented with the goal of aiding in proper treatment with these two medications. Specific attention is given to doses in special situations, means of drug monitoring, strategies for avoiding antibiotic resistance, alternative medication choices, and areas for future investigation.

Nosocomial coagulase negative staphylococcal (CoNS) catheter-related sepsis in preterm infants: definition, diagnosis, prophylaxis, and prevention

Nosocomial infections with coagulase negative staphylococcus (CoNS) are a frequent and significant cause of morbidity in the preterm infant. Infections diagnosed after the first 72 hours of life are arbitrarily deemed to be "nosocomial." There are many difficulties encountered in efforts to evaluate and compare nosocomial sepsis in the NICU. An issue of primary concern is the lack of uniformity in the definition of sepsis in the NICU. Based on the frequency of positive blood cultures in infants less than 1000 g, it appears reasonable to evaluate methods for the prevention of nosocomial sepsis. These include prophylactic antibiotic administration, antiseptic impregnated catheters, and the use of an antibiotic lock technique.

Vancomycin for prophylaxis against sepsis in preterm neonates

BACKGROUND

Nosocomial, late onset sepsis occurs in up to 50% of infants of less than 1000gm at birth. The commonest organism isolated is coagulase negative staphylococcus (CoNS). A number of studies have evaluated the efficacy or prophylactic low dose vancomycin given either as a continuous infusion added to the infant's hyperalimentation fluid or by intermittent intravenous administration and these studies in very low birth weight infants are the subject of this review.

OBJECTIVES

To evaluate the safety and efficacy of vancomycin prophylaxis for the prevention of late-onset sepsis, coagulase negative staphylococcal sepsis, mortality, and effects on length of stay, total vancomycin exposure, evidence of vancomycin toxicity, and the development of vancomycin resistant organisms in the preterm neonate.

SEARCH STRATEGY

Searches were made of Medline, (MeSH terms: Vancomycin and Sepsis; limits: age groups, newborn infants), HealthStar and EMBase, electronic abstracts, personal files and conference proceedings.

SELECTION CRITERIA

Randomized controlled trials which compared the incidence of sepsis and mortality in preterm neonates receiving vancomycin prophylaxis versus a control group receiving no prophylaxis.

DATA COLLECTION AND ANALYSIS

Data regarding clinical outcomes including the overall incidence of sepsis, the incidence of coagulase negative staphylococcal sepsis, mortality, length of stay, total vancomycin exposure, evidence of vancomycin toxicity, and the development of vancomycin resistant organisms were excerpted from previous clinical trials. Data analysis was done in accordance with the standards of the Cochrane Neonatal Review Group.

MAIN RESULTS

The administration of prophylactic vancomycin reduced the incidence of both total neonatal nosocomial sepsis and coagulase negative staphylococcal sepsis in eligible preterm infants. Mortality, length of stay, and evidence of vancomycin toxicity were not significantly different between the two groups. There was insufficient evidence to ascertain the risks of development of vancomycin resistant organisms in the nurseries involved in these trials.

REVIEWER'S CONCLUSIONS

The use of prophylactic vancomycin in low doses reduces the incidence of nosocomial sepsis in the neonate. The methodologies of these studies may have contributed to the low rate of sepsis in the treated groups, as the blood cultures drawn from central lines may have failed to grow due to the low levels of vancomycin in the infusate. Although there is a theoretical concern regarding the development of resistant organisms with the administration of prophylactic antibiotic, there is insufficient evidence to ascertain the risks of development of vancomycin resistant organisms. Few clinically important benefits have been demonstrated for very low birth weight infants treated with prophylactic vancomycin. It therefore appears that routine prophylaxis with vancomycin should not be undertaken at present.

Antibiotics in neonatal infections: a review

The bacteria most commonly responsible for early-onset (materno-fetal) infections in neonates are group B streptococci, enterococci, Enterobacteriaceae and Listeria monocytogenes. Coagulase-negative staphylococci, particularly Staphylococcus epidermidis, are the main pathogens in late-onset (nosocomial) infections, especially in high-risk patients such as those with very low birthweight, umbilical or central venous catheters or undergoing prolonged ventilation. The primary objective of the paediatrician is to identity all potential cases of bacterial disease quickly and begin antibacterial treatment immediately after the appropriate cultures have been obtained. Combination therapy is recommended for initial empirical treatment in the neonate. In early-onset infections, an effective first-line empirical therapy is ampicillin plus an aminoglycoside (duration of treatment 10 days). An alternative is ampicillin plus a third-generation cephalosporin such as cefotaxime, a combination particularly useful in neonatal meningitis (mean duration of treatment 14 to 21 days), in patients at risk of nephrotoxicity and/or when therapeutic monitoring of aminoglycosides is not possible. Another potential substitute for the aminoglycoside is aztreonam. Triple combination therapy (such as amoxicillin plus cefotaxime and an aminoglycoside) could also be used for the first 2 to 3 days of life, followed by dual therapy after the microbiological results. In late-onset infections the combination oxacillin plus an aminoglycoside is widely recommended. However, vancomycin plus ceftazidime (+/- an aminoglycoside for the first 2 to 3 days) may be a better choice. Teicoplanin may be a substitute for vancomycin. However, the initial approach should always be modified by knowledge of the local bacterial epidemiology. After the microbiological results, treatment should be switched to narrower spectrum agents if a specific organism has been identified, and should be discontinued if cultures are negative and the neonate is in good clinical condition. Penicillins and third-generation cephalosporins are generally well tolerated in neonates. There is controversy regarding whether therapeutic drug monitoring of aminoglycosides will decrease toxicity (particularly renal damage) in neonates, and on the efficacy and safety of a single daily dose versus multiple daily doses of these drugs. Toxic effects caused by vancomycin are uncommon, but debate still exists over the need for therapeutic drug monitoring of this agent. When antibacterials are used in neonates, accurate determination of dosage is required, particularly for compounds with a low therapeutic index and in patients with renal failure. Very low birthweight infants are also particularly prone to antibacterial-induced toxicity.