Neonatal sepsis

• Neonatal sepsis is caused by infection in the neonatal period (<28 days)

  • Potentially results in significant morbidity and mortality
  • Presents with non-specific signs and requires high degree of suspicion and a low threshold for starting broad spectrum antibiotics
• Common organisms:

  • Group B streptococcus
  • E. coli
  • Listeria
  • Klebsiella
  • Staphylococcus aureus
• GBS:

  • Common bacteria found in up to 25% of women - located in the vagina
  • Women tested for it at around 35-37 weeks pregnant via swab and culture
  • Does not cause any symptoms in the woman
  • If woman found to be GBS positive will be given prophylactic antibiotics
• Risk factors:

  • Vaginal GBS colonisation
  • GBS sepsis in a previous baby
  • Maternal sepsis or fever >38
  • Chorioamnionitis - infection of placenta and membranes
  • Prematurity (less than 37 weeks)
  • Premature rupture of membrane
  • Prolonged rupture of membrane
• Clinical features:

  • Fever
  • Reduced tone and activity
  • Poor feeding
  • Respiratory distress or apnoea
  • Vomiting
  • Tachycardia or bradycardia
  • Hypoxia/cyanosis
  • Jaundice within 24 hours
  • Seizures
  • Bulging fontanelle
  • Hypo or hyperglycaemia
• Red flags:

  • Confirmed or suspected sepsis in the mother
  • Signs of shock
  • Seizures
  • Term baby needing mechanical ventilation
  • Respiratory distress starting more than 4 hours after birth
  • Presumed sepsis in another baby in multiple pregnancy
• When to initiate treatment:

  • If there is 1 risk factor or clinical feature = monitor
  • 2 or more risk factors or clinical features = start antibiotics
  • 1 red flag = start antibiotics
• Investigations:

  • Blood cultures - before antibiotics
  • Bloods - VBG, lactate, FBC, U&Es, CRP
  • Lumbar puncture - if infection strongly suspected or signs of meningitis
  • Urine culture
  • Swabs of specific lesions
  • Chest X-ray +/- abdominal x-ray if specific signs on exam
• Do not perform lumbar puncture if:

  • Extensive or rapidly spreading purpura
  • Infection at lumbar puncture site
  • Risk factors for an evolving space-occupying lesions
  • Signs of raised ICP
• Early onset neonatal sepsis = within first 48-72 hours of life, risk factors:

  • Prematurity
  • Low birth weight
  • Prolonged rupture of membranes (>18 hours)
  • Maternal GBS colonisation
  • Maternal infection during labour e.g. chorioamnionitis
  • Most common organisms = GBS, E. coli, listeria
• Late onset neonatal sepsis = between 72 hours and 28 days

  • Prematurity
  • Low birth weight
  • Tends to be caused by organisms associated with hospital environments and invasive procedures e.g. intubation
  • Common organisms = Staph. epidermidis, Staph. aureus, Klebsiella
• Early onset-sepsis antibiotics:

  • Benzylpenicillin plus gentamicin (IV)
  • Add cefotaxime (IV) if cultures show evidence of gram-negative infection
• IV fluid resus =

  • 10-20ml/kg
  • Isotonic fluid e.g. NS
  • Over 1-2 hours
• Hypoglycaemia:

  • 2ml/kg
  • 10% dextrose
• Ongoing management:

  • Check CRP again at 24 hours
  • Check blood culture results at 36 hours
  • Consider stopping antibiotics if baby is clinically well, the lumbar puncture and blood cultures are negative and the CRP has returned to normal at 5 days
  • If positive blood culture antibiotics normally continued for 7 days
• GBS is a common cause of both early and late onset neonatal sepsis
• Late onset sepsis antibiotics:

  • Flucloxacillin (or vancomycin) plus gentamicin (IV)
• Specific situations:

  • Give amoxicillin and cefotaxime (IV) if meningitis is suspected
  • Add metronidazole if NEC is suspected
  • Add an antifungal (e.g. amphotericin B) if fungal sepsis is suspected (high-risk baby with a negative blood culture)
  • Add aciclovir (IV) if HSV infection is suspected (e.g. vesicular rash, late-onset sepsis with respiratory disease or sepsis not responding to antibiotics)