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Section 8 — Infectious Disease & Sepsis Verify against local policy v1.0 · July 2026 Baylor Ed. 33 cross-checked Sept 2026

Chapter 8.2 — Late-Onset Sepsis & NICU-Acquired Infection

Built on West Midlands Neonatal Guidelines 2025–28 (Infection – Late Onset) · NICE NG195 · AAP/CDC HAI prevention · Baylor Guidelines for Acute Care of the Neonate

Educational guideline — verify locally. Empirical regimens for late-onset/hospital-acquired infection are highly unit- and antibiogram-specific; verify all agents and doses against your Neonatal Formulary and local antimicrobial policy. Does not replace attending judgment.
BEDSIDE ACTION BOX — Suspected LOS

1. Overview & Definition

Overview

Late-onset sepsis (LOS) is infection arising more than 72 hours after birth, most often hospital-acquired in preterm infants with central lines and parenteral nutrition. Its microbiology is broader than early-onset sepsis — dominated by coagulase-negative staphylococci (CoNS), with a significant contribution from Gram-negative bacteria (increasingly gentamicin-resistant) and Candida. Because presentation is subtle and non-specific, a low threshold for evaluation, combined with rigorous prevention (hand hygiene, line-care bundles) and antimicrobial stewardship, is central.

Why This Topic Matters

LOS is a leading cause of morbidity, mortality, prolonged stay, and adverse neurodevelopment in preterm infants. Prevention (especially central-line and hand-hygiene bundles and early human-milk feeding) prevents more harm than any treatment, and distinguishing true CoNS infection from blood-culture contamination avoids both under- and over-treatment.

Definition

LOS is invasive infection with onset >72 hours after birth (some definitions use >7 days), including bacteraemia, meningitis, urinary tract infection, central-line-associated bloodstream infection (CLABSI), pneumonia, and invasive fungal infection.

2. Who This Guideline Applies To

Scope
  • Neonates >72 hours old with suspected infection, especially preterm/low-birth-weight infants with central catheters, parenteral nutrition, ventilation, or recent surgery.
  • Infants being risk-managed for hospital-acquired infection and those on antifungal prophylaxis pathways.
  • Cross-references: early-onset sepsis (8.1), congenital infections (8.3), NEC (11.1), meningitis, and central-line care bundles.

3. Key Definitions

Core Terminology

Terms used across the LOS and healthcare-associated-infection pathway.

TermDefinitionPractical note
LOSInvasive infection >72 h after birth.Mostly hospital-acquired in preterm infants.
CoNSCoagulase-negative staphylococci.~50% of LOS; also the commonest blood-culture contaminant — interpret carefully.
CLABSICentral-line-associated bloodstream infection.Prevent with insertion/maintenance bundles; remove unnecessary lines.
HAIHealthcare-associated (nosocomial) infection.Hand hygiene is the single most effective preventive measure.
Invasive candidiasisSystemic Candida infection.Consider in ELBW infants on broad-spectrum antibiotics/PN; can seed eyes, brain, kidneys, heart.

4. Organisms & Risk Factors

Typical Microbiology

The spectrum is broader than EOS and shifts with local resistance patterns — always consult your unit antibiogram.

GroupExamplesNote
Gram-positive (majority)Coagulase-negative staphylococci (~50%), Staph. aureus, enterococci.CoNS often line-associated; distinguish true infection from contaminant.
Gram-negative (~20–40%)Klebsiella > Serratia > Enterobacter > Pseudomonas > E. coli, Acinetobacter.Increasingly gentamicin-resistant; can cause fulminant sepsis.
FungalCandida species.ELBW, prolonged antibiotics/PN, central lines; needs specific antifungal therapy.
Risk Factors

Prematurity and low birth weight; central venous catheters; parenteral nutrition; mechanical ventilation; recent surgery (especially gut surgery/stoma, post-gastroschisis or NEC); and delayed establishment of enteral feeds. If one infant of a multiple birth is infected, actively consider the others.

5. Prevention (Highest Yield)

Prevention Bundle
  • Hand hygiene — the single most effective measure; follow the WHO "5 moments," bare below the elbow, no jewellery except a wedding band, alcohol hand rub and hand washing.
  • Central-line bundles — sterile insertion, daily necessity review, aseptic access, meticulous changing of administration sets/3-way taps, and prompt removal of unnecessary lines.
  • Early enteral feeding with mother's own milk (ideally within ~6 hours of birth) and avoiding prolonged parenteral nutrition.
  • Antimicrobial stewardship (shortest effective courses); consider antifungal prophylaxis in ELBW infants in units with high invasive-Candida incidence.
  • Cohorting/isolation and environmental cleaning during outbreaks.
What "hand hygiene" means in practice (Baylor Ed. 33)
  • Bare below the elbow — fingertips to elbows free of jewellery (one plain band ring without stones is the exception), watches and white coats, with sleeves above the elbows, throughout the patient space.
  • On first entry to the unit for the day or shift, and after meals: a three-pump alcohol-and-chlorhexidine application from fingertips to elbows, starting with dry hands and a nail pick under the nails — first pump worked under the nails of the opposite hand and spread to the elbow, second pump the same on the other side, third reapplied to hands and wrists. It should take 30–60 seconds. The same process applies before any invasive sterile procedure — umbilical catheter, chest tube, lumbar puncture, percutaneous catheter, exchange transfusion, pericardiocentesis, thoracentesis, paracentesis.
  • Soap and water — at least 20 seconds of vigorous scrubbing — whenever hands are visibly soiled, after caring for a patient on special contact precautions (C. difficile, norovirus) and after the toilet. Otherwise alcohol rub is preferred: rub until dry, no fanning or towelling.
  • The patient space is the whole room from the doorway in a single room, or the bed and all surrounding equipment, counters, cabinets, chart and visitor chairs in an open pod. Each patient needs a dedicated stethoscope, cleaned with alcohol before and after each use, and charts count as dirty. Multiples in one room are handled separately and share no equipment.
  • Gowns: not required to enter the NICU, but worn by anyone holding an infant against their clothing (skin-to-skin excepted). Liquid-impermeable gowns are for isolation areas only and must not be worn outside them. Masks, head covers, beard bags and sterile gowns for any sterile procedure, including for assistants who stay in the room.
Line infections, and what the culture does not tell you

Baylor treats a suspected CLABSI with nafcillin and amikacin, and removes the catheter when the organism is yeast, enterococcus, a Gram-negative rod, S. aureus, or when several organisms grow — immediately in an infant who stays septic on antibiotics or develops secondary foci on therapy. Initial cultures come from two sources, one central and one peripheral; follow-up cultures usually need only one source at 24-hour intervals until two consecutive negatives. Suspected disseminated staphylococcal infection: vancomycin and nafcillin with amikacin until susceptibilities return — nafcillin beats vancomycin against MSSA. Bone or joint infection: vancomycin, nafcillin and amikacin, with early ID input on surgery. A tracheal aspirate growing a pathogen does not establish pneumonia — it may be tube colonization. Below 1500 g a clean catheter urine can be hard to get and a bladder tap may be needed; urine culture is always indicated in that weight group for suspected fungal infection, known renal anomalies, or more than one episode of Gram-negative bacteraemia without a source.

MRSA / MSSA surveillance and decolonization

Decolonization significantly reduces invasive infection in colonized infants. Baylor screens on admission and weekly by PCR — more sensitive than culture, and the gold standard.

OrganismTestingIsolationDecolonization
MRSAOn admission, then weekly. Stop weekly testing once positive.Contact precautions until discharge, whether or not decolonizedOnce during the admission
MSSAOn admission, then weekly. Continue weekly testing if positive, to detect MRSAStandard precautionsOnce during the admission — twice only if the infant becomes MRSA positive after MSSA decolonization
AgeMupirocinBath
≥36 weeks PMA or ≥4 weeks chronological ageTo the nares twice daily for 5 daysChlorhexidine wipe bath daily for 5 days, alongside the mupirocin
<36 weeks PMA and <4 weeks chronological ageTo the nares twice daily for 5 daysRegular bath per protocol — no chlorhexidine wipes

Chlorhexidine binds to skin and keeps working for at least 24 hours after application, and bathing neonates with CHG wipes reduces central-line bloodstream infections. Trace amounts are absorbed through the skin on limited data, with no clinical sequelae reported in neonates — which is why the youngest and most premature infants are decolonized with mupirocin alone.

6. Presentation

Often Subtle & Non-Specific
  • Behaviour: caregiver/clinician concern, lethargy, weak/high-pitched cry, not staying awake.
  • Respiratory: apnoea, increased work of breathing, rising oxygen need, tachypnoea (≥60/min).
  • Circulation: persistent tachycardia (≥160) or bradycardia (<100), poor perfusion, mottled/ashen skin, non-blanching rash.
  • GI: feed intolerance, abdominal distension/tenderness, reduced bowel sounds, blood in stool (overlaps with NEC).
  • Other: temperature <36°C or ≥38°C; reluctance to move a limb (osteomyelitis/septic arthritis); septic skin/umbilical/nail spots; bulging fontanelle/seizures (meningitis); petechiae.

7. Management Algorithm

1
Recognise instability >72 h
New apnoea, temperature instability, feed intolerance, increased support, or clinical concern → suspect LOS.
2
Culture before antibiotics
Peripheral blood culture (aseptic, closed system); FBC/CRP; urine (SPA/catheter) if >72 h; LP if suspicion of meningitis/positive culture; swab suspicious lesions; review recent swabs/ETT cultures.
3
Start empirical antibiotics (local policy)
Default nafcillin + an aminoglycoside (vancomycin instead of nafcillin if MRSA-colonised); UK: flucloxacillin + gentamicin, vancomycin + gentamicin for line/CoNS. Match to your antibiogram. Escalate Gram-negative cover for severe illness/known resistance.
4
Consider fungal & source control
Add antifungal (e.g., amphotericin/fluconazole per policy) if Candida risk. Assess every line: remove or replace infected/unneeded catheters. Consider imaging for focal sources (abscess, osteomyelitis, endocarditis).
5
Reassess at 48 h
Cultures negative and baby well → stop/de-escalate. True infection → tailor to sensitivities; treat for appropriate duration; repeat blood culture to confirm clearance (especially CoNS/CLABSI, Candida).
6
⚠ Do-not-miss
Meningitis (LP), invasive candidiasis (end-organ screen: eyes/brain/renal/cardiac), NEC, endocarditis on an infected line, and osteomyelitis/septic arthritis (reluctance to move a limb). A single CoNS from a line hub may be a contaminant — interpret with the clinical picture and repeat cultures.

8. Investigations

Before Starting Antibiotics
  • Blood culture from a peripheral vein using a closed, non-touch aseptic system (hub samples risk CoNS contamination); an adequate blood volume improves yield.
  • FBC (neutrophils <2 or >15 ×10⁹/L, or platelets <100 ×10⁹/L are supportive but not diagnostic) and CRP trend.
  • Urine (suprapubic aspirate or catheter) — UTI is relevant in LOS (unlike EOS).
  • Lumbar puncture when meningitis is suspected or blood culture is positive.
  • Swab suspicious lesions; review recent surveillance/ETT cultures to guide therapy; imaging for suspected focal infection.

9. Antibiotics, Antifungals & Duration

Empirical Therapy (Default: Baylor Ed. 33 — Match to Local Antibiogram)

For infants over 72 hours old in continuous NICU care. Doses and levels are in section 9+ below; de-escalate on cultures.

ScenarioCommon empirical regimenNotes
General LOS (default)Nafcillin + an aminoglycoside (Baylor uses amikacin).Covers S. aureus and Gram-negatives; de-escalate on cultures. 48-hour rule-out; 7–10 days of organism-specific therapy if positive.
MRSA-colonised, or central line / suspected CoNSVancomycin in place of nafcillin, with the aminoglycoside.Reserve vancomycin for these indications; monitor levels.
Severe / Gram-negative concernAdd/broaden Gram-negative cover (e.g., piperacillin-tazobactam or meropenem) per antibiogram.Consider local resistance (ESBL); avoid ceftriaxone in neonates.
MeningitisNafcillin + ceftazidime at meningeal doses.Higher doses, longer duration; repeat LP as indicated.
Readmitted from homeFebrile-infant pathway, not this table: ampicillin + an aminoglycoside at 0–21 days; ceftazidime instead of the aminoglycoside if meningitis or CSF pleocytosis is a concern; aciclovir if HSV is a concern.Community organisms differ from NICU flora.
Invasive candidiasisAmphotericin B (or fluconazole per susceptibility/policy).Remove lines; screen eyes/brain/renal/cardiac; involve micro/ID.
Other sources: UKFlucloxacillin + gentamicin; vancomycin + gentamicin for line/CoNS; cefotaxime + amoxicillin/ampicillin ± vancomycin for meningitis.Match to local resistance data.
Duration & Stewardship
  • Stop or de-escalate at 48 h (some units 48–72 h) if cultures are negative and the baby is well.
  • Confirmed bacteraemia ~7–10 days (organism-dependent); CoNS/CLABSI often ~5–7 days with line removal and documented clearance; meningitis ~14–21 days; invasive candidiasis ~2–3 weeks after clearance with line removal.
  • Document blood-culture clearance for CoNS, Staph. aureus, and Candida; remove infected lines.
Evidence & Uncertainty
  • CoNS interpretation: a single positive from a line hub in a well baby may be a contaminant; repeat peripheral culture and correlate clinically before committing to vancomycin.
  • Antifungal prophylaxis: fluconazole prophylaxis reduces invasive candidiasis in ELBW infants in high-incidence units (unit-dependent).
  • Doses and drug levels: Baylor Tables 19-3 and 19-4 below.

9+. Neonatal Urinary Tract Infection (Baylor Ed. 33)

UTI runs through the late-onset sepsis workup but has its own diagnostic thresholds, and the neonatal numbers differ from the paediatric ones most people carry in their heads.

How common, and in whom
  • 0.1–1% of all neonates, but up to 10% of low birth weight (<2500 g), 12–25% of VLBW (<1500 g) and 6–14% of ELBW infants. In the first year boys predominate (3.7% versus 2%); afterwards girls do.
  • E. coli causes up to 90% in infants under 3 months. Enterococcus rarely produces pyuria because it provokes little inflammatory response — a negative urinalysis does not exclude it. Pseudomonas, group B streptococcus and S. aureus point to congenital anomalies, genitourinary surgery, a foreign body or recent antibiotics; Proteus and other urea-splitting organisms to calculi. In low birth weight infants, most UTIs occur with negative blood cultures.
  • Neonatal urinalysis is less likely to show pyuria, leukocyte esterase or nitrites than in older children — the laboratory indices are neither sensitive nor specific here.
  • Renal scarring follows up to 15% of first febrile UTIs and rises with recurrence; recurrence risk in the 6–12 months after a first UTI is 12–30%.
Collection methodThreshold for diagnosis
Catheter specimen≥50,000 CFU/mL, or 10,000–50,000 CFU/mL with pyuria, leukocyte esterase or nitrites on urinalysis
Clean catch≥100,000 CFU/mL — rare in this population; consider with a sterile external collection device
Suprapubic aspirationAny growth
Treatment, imaging and prophylaxis
  • Send both a urine culture and a urinalysis. If the catheter specimen is too small for both, use it for the culture and collect a bag specimen for the urinalysis, which only guides the diagnosis. Suprapubic aspiration is the alternative when the urethra cannot be visualized, in uncircumcised boys with an unretractable foreskin, after repeated failed catheterizations, or after urethral or introital surgery — avoid it if the infant has just voided, has abdominal distension, poorly defined urinary tract anomalies, or a bleeding risk.
  • Empiric therapy mirrors sepsis — ampicillin with an aminoglycoside. Baylor uses amikacin rather than gentamicin because of prior high E. coli gentamicin resistance locally; let your own uropathogen susceptibilities decide.
  • Treat for 7 days. Preterm infants get the full course intravenously — oral bioavailability, safety and efficacy are unknown in that population. In a term infant over 4–6 weeks, start IV and consider switching to oral only if the infant is clinically well with normal laboratory findings and negative blood and CSF cultures, is improving, and IV access is difficult.
  • Urine should sterilize within 48 hours. Proof-of-cure cultures are unnecessary unless improvement is delayed or the organism proves intermediate or resistant — then repeat after 48–72 hours of appropriate therapy.
  • Imaging: renal ultrasound for every infant with a febrile UTI, even if the third-trimester prenatal scan was normal — after a single UTI, obtain it once the infant is beyond 37 weeks or before discharge. Renal ultrasound plus VCUG after two or more UTIs, or after a first UTI with an abnormal ultrasound, an atypical pathogen, a complex course or known scarring. Bring the ultrasound forward into the acute episode if the illness is unusually severe or fever persists beyond 48–72 hours. Vesicoureteral reflux on VCUG warrants a urology consult.
  • Prophylaxis: the American Urological Association recommends continuous prophylaxis in children under 1 year with significant reflux and a febrile UTI; the RIVUR trial showed trimethoprim-sulfamethoxazole halved UTI risk. Under 2 months: IV ampicillin 25 mg/kg once daily or oral amoxicillin 10 mg/kg/day once daily. Over 2 months: oral trimethoprim-sulfamethoxazole 2–3 mg/kg once daily — amoxicillin resistance is higher in that age group.

Antimicrobial Dosing and Drug Levels (Baylor Ed. 33, Tables 19-3 and 19-4)

Initial doses and intervals by gestational age (GA), postnatal age (PNA) or weight. Renal clearance tracks postmenstrual age, so intervals lengthen in the most immature infants. Re-dose for weight weekly, involve pharmacy in renal dysfunction, and verify against your formulary.

DrugDose and interval
AmpicillinEarly-onset sepsis: 100 mg/kg every 8 h. Other non-CNS infection: GA ≤34 wk — 50 mg/kg every 12 h (PNA ≤7 d), 75 mg/kg every 12 h (>7 d); GA 35–43 wk — 50 mg/kg every 8 h; GA ≥44 wk — 12.5–50 mg/kg every 6 h (severe 50–67 mg/kg every 4 h). Meningitis (including GBS): 100 mg/kg every 8 h (PNA ≤7 d), 75 mg/kg every 6 h (>7 d). Asplenia prophylaxis 50 mg/kg IV every 12 h; UTI prophylaxis 25 mg/kg IV every 24 h.
GentamicinGA <30 wk — 5 mg/kg every 48 h (PNA ≤14 d), every 36 h (>14 d); GA 30–34 wk — 5 mg/kg every 36 h (≤14 d), every 24 h (>14 d); GA 35–43 wk — 4 mg/kg every 24 h (≤7 d), 5 mg/kg every 24 h (>7 d); GA ≥44 wk — 2.5 mg/kg every 8 h
AmikacinGA <30 wk — 15 mg/kg every 48 h (PNA ≤14 d), every 24 h (>14 d); GA 30–34 wk — 15 mg/kg every 24 h (PNA ≤60 d); GA 35–43 wk — 15 mg/kg every 24 h (≤7 d), 17.5 mg/kg every 24 h (>7 d); GA ≥44 wk — 5–7.5 mg/kg every 8 h
Vancomycin15 mg/kg per dose: <1.2 kg every 18–24 h (PNA ≤28 d); 1.2–2 kg every 12–18 h (<7 d), every 8–12 h (≥7 d); >2 kg every 8–12 h (<7 d), every 6–8 h (≥7 d)
NafcillinNon-CNS: GA ≤34 wk 25 mg/kg every 12 h (≤7 d), every 8 h (>7 d); GA 35–43 wk every 8 h (≤7 d), every 6 h (>7 d); ≥44 wk 25–50 mg/kg every 6 h. Meningitis: <44 wk 25 mg/kg every 8 h (≤7 d), 25–37.5 mg/kg every 6 h (>7 d); ≥44 wk 50 mg/kg every 6 h
Ceftazidime50 mg/kg per dose: <1 kg every 12 h (PNA ≤14 d), every 8 h (>14 d); 1–2 kg every 12 h (≤7 d), every 8–12 h (>7 d); >2 kg every 12 h (≤7 d), every 8 h (8–60 d). Meningitis: every 8–12 h (≤7 d), every 8 h (>7 d)
Clindamycin5 mg/kg per dose: <1 kg every 12 h (≤14 d), every 8 h (>14 d); 1–2 kg every 12 h (≤7 d), every 8 h (>7 d); >2 kg every 8 h (≤7 d), every 6 h (8–28 d)
Penicillin GNon-CNS (including GBS): 50,000 units/kg every 12 h (PNA ≤7 d), every 8 h (8–28 d); GBS 29–60 d every 6 h (printed "50,0000" — read as 50,000). GBS meningitis: 84,000–150,000 units/kg every 8 h (0–7 d), 100,000–125,000 units/kg every 6 h (8–28 d), 100,000 units/kg every 6 h (29–60 d). Other meningitis: 50,000 units/kg every 8 h (0–7 d), every 6 h (8–28 d)
Amoxicillin (PO)UTI prophylaxis 10 mg/kg every 24 h; asplenia prophylaxis 10 mg/kg every 12 h
Zidovudine (PO, low-risk HIV exposure)GA <30 wk 2 mg/kg every 12 h; GA 30–34 wk 2 mg/kg every 12 h (≤14 d) then 3 mg/kg; GA ≥35 wk 4 mg/kg every 12 h — each through 4–6 weeks (see chapter 8.6)
Drug level (Table 19-3)WhenGoalNotes
GentamicinPeak 30 min after infusion ends; trough 30 min before next dosePeak 8–10 (life-threatening), 6–10 (serious), 4–6 (UTI); trough <1.5 mcg/mLPeak reflects efficacy only; trough reflects safety only. Hold a dose awaiting the trough only when the level was drawn for renal dysfunction.
AmikacinSame timingPeak 25–40 (life-threatening), 20–25 (serious), 15–20 (UTI); trough <8 mcg/mL
VancomycinTrough 30 min before next dose8–20 mcg/mL by indication and siteReflects both safety and efficacy.
PhenobarbitalTrough before a maintenance dose20–40 mcg/mLRetime with the team if no maintenance dose has been given yet.
Phenytoin / fosphenytoinTrough before a maintenance doseTotal 15–20; free 1–2 mcg/mL (toxicity concern >4)Order free and total levels — neonatal protein binding is unreliable.

10. Monitoring

Monitoring Table

Track response, drug levels, and clearance; escalate if deteriorating.

ParameterFrequencyTarget / watchAction if abnormal
Clinical status / vitalsContinuousImprovingDeterioration → escalate, broaden, source control.
Blood culture (repeat)To confirm clearanceNegativePersistent positivity → line removal, imaging, ID advice.
CRP / FBC / plateletsSerialTrending down; platelets recoveringRising/persistent → seek focus.
Vancomycin / gentamicin levelsPer TDMTherapeutic/safeAdjust dose/interval.
Candida end-organ screenIf candidaemiaNo end-organ diseaseOphthalmology, cranial/renal/cardiac imaging; extend therapy.
Central line necessityDailyRemove when not neededRemove/replace infected lines promptly.

11. Contraindications & Precautions

Safety Cautions
  • Do not overuse vancomycin — reserve for likely CoNS/line infection to limit resistance; de-escalate promptly.
  • Interpret CoNS carefully (contaminant vs true infection) — avoid treating contaminants, but don't dismiss true infection in a sick baby with a line.
  • Avoid ceftriaxone in neonates; be alert to rising Gram-negative resistance (choose empirical cover from the local antibiogram).
  • Monitor vancomycin and gentamicin levels (nephro/ototoxicity).
  • Do not leave infected or unnecessary central lines in situ.
  • Consider and treat invasive candidiasis in high-risk infants; screen for end-organ disease.
  • Remember LOS and NEC overlap — evaluate the abdomen.

12. Escalation

Escalate When…
  • Septic shock or rapid deterioration — resuscitate, broaden cover, and escalate support urgently.
  • Positive cultures (especially Gram-negative, Staph. aureus, or Candida), meningitis, endocarditis, or persistent bacteraemia — involve microbiology/infectious diseases and consider imaging/echo and line removal.
  • Suspected outbreak or multidrug-resistant organism — infection prevention and control.
Parent Counselling Points
  • "Your baby has shown signs of a possible infection acquired after birth, which is more common in premature babies with drips and lines. We've taken cultures and started antibiotics."
  • "We check every day whether lines are still needed and remove them promptly, because they can be a source of infection."
  • "If the cultures are clear and your baby is well, we stop antibiotics; if an infection is confirmed, we complete the right course. Clean hands are the best protection — for all of us."

13. Key Pearls

High-Value Clinical Pearls
  • LOS is broad-spectrum: CoNS dominates, but Gram-negatives (often resistant) and Candida cause the sickest infants.
  • Prevention beats treatment — hand hygiene and line bundles, early human-milk feeds, and removing unnecessary lines.
  • Peripheral, aseptic blood culture; add urine and LP (unlike EOS, UTI matters).
  • Match empirical antibiotics to your unit antibiogram; reserve vancomycin for likely CoNS/line infection.
  • Interpret a single CoNS carefully — contaminant vs true infection.
  • Consider invasive candidiasis in ELBW infants on broad-spectrum antibiotics/PN and screen for end-organ spread.

14. Common Mistakes to Avoid

Pitfalls & Better Practice

The recurring errors in late-onset/hospital-acquired infection.

MistakeWhy it harmsBetter practice
Routine empirical vancomycin.Drives resistance.Reserve for likely CoNS/line infection; de-escalate.
Sampling only from a line hub.CoNS contamination, false positives.Peripheral, aseptic, adequate-volume culture.
Ignoring the central line.Ongoing CLABSI source.Daily necessity review; remove/replace infected lines.
Empirical choice not matched to antibiogram.Under-treats resistant Gram-negatives.Use local resistance data; broaden when severe.
Forgetting Candida.Missed invasive fungal disease.Cover/screen high-risk ELBW infants.
Not confirming clearance.Relapse (CoNS/Candida/S. aureus).Repeat cultures; complete appropriate duration.

15. Board-Style High-Yield Summary

Key Takeaways
  • LOS = infection >72 h; CoNS ~50%, Gram-negatives 20–40% (often gentamicin-resistant), plus Candida.
  • Risk: prematurity, central lines, PN, ventilation, surgery, delayed feeds.
  • Prevention: hand hygiene + line bundles + early human milk; the biggest lever.
  • Work-up: peripheral blood culture (aseptic), FBC/CRP, urine, LP as indicated; review recent cultures.
  • Empirical: nafcillin + an aminoglycoside (vancomycin if MRSA-colonised or line/CoNS); UK flucloxacillin + gentamicin; add antifungal for Candida risk; avoid ceftriaxone.
  • Reassess at 48 h; de-escalate/stop if negative; remove infected lines; confirm clearance.

16. References

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