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Editor—We read with interest the article by Isaacs on the rationing of antibiotic use in neonatal units.1 This encourages the use, where possible, of flucloxacillin and an aminoglycoside as empiric treatment of late onset sepsis.
While this represents a valid approach to the empiric treatment of late onset infection, the epidemiology of bacterial sepsis will vary from unit to unit. In our unit we use a combination of vancomycin and cefotaxime. In 1999, of 159 positive blood cultures, coagulase negative staphylococci were isolated from 124 (78%). All were sensitive to vancomycin, but only 63% were resistant to netilmicin, 89% to cefotaxime, and 91% to flucloxacillin. In most cases, there was a sudden rather than insidious deterioration in the baby with raised C reactive protein, suggesting true infection rather than contamination. This is further supported by the fact that in 94% of cases a coagulase negative staphylococcus was the sole isolate and the patients responded to appropriate treatment.
Although we consider the use of vancomycin to be essential for empiric treatment of late onset sepsis, we are aware of the problems associated with its overuse. The emergence of vancomycin resistant organisms including vancomycin resistant enterococci and vancomycin insensitive Staphylococcus aureus is, of course, a concern, but, in spite of continuing surveillance, this has not been observed in our unit. We agree that, to prevent the emergence of resistant gram positive organisms, it is vitally important to stop vancomycin treatment if cultures are negative after 48 hours. Some 96% of blood cultures that grow an organism do so within 48 hours,2 and discontinuation after this time is not associated with increased morbidity.3
In conclusion, we would suggest that antibiotic policies remain unit specific, based on the prevalent microorganisms and their known sensitivities.