Neonatal Sepsis

Overview

Definiton of terms

SIRS criteria (≥ 2 required, 1 must be abnormal temperature or leukocyte count)

Temp > 38.5 C or < 36 C

Abnormal leucocyte count OR > 10% band

Tachycardia, OR Bradycardia (if < 1 year)

Tachypnea, OR Mechanical ventilation (related to an acute process)

• Causative orgasnisms of EOS
  • Group B Streptococci
  • Escherichia coli
  • CoNS (Coagulase negative) – Staphylococcus epidermidis
  • Haemophilus influenza
  • Listeria monocytogenes
• Causes of LOS
  • CoNS (Staphylococcus epidermidis; >50%)
  • Staphylococcus Aureus
  • Hemophilus influenza
  • Klebsiella
  • Pseudomonas
  • Viral causes
  • Candida
• Risk factors for EOS
  • PROM (> 18 hours)
  • Maternal infection
    • Intrapartum maternal fever (> 38 C)
    • Chorioamnionitis
    • UTI
  • Difficulty delivery
  • Vaginal carriage – evidenced by previous infant with GBS
  • Asphyxia
• Risk factors for LOS
  • Hospitalisation
  • Instrumentation
    • Umbilical catheterization
    • Endotracheal intubation
    • Intravascular catheter insertion
  • Congenital malformations
    • Spina bifida
    • Tracheo-esophageal fistula
    • Congenital heart disease
  • Severe illness
    • Immunodeficiency
    • Malnutrition

Note: Premature and LBW (3-10 times higher than term babies with normal birth weight) is a risk factor for both EOS and LOS due to:

• Deficient immunity (IgG, opsonization, complement)
• Immature epithelial barrier
• Increased need for invasive devices (vascular access, endotracheal tube, feeding tubes, urinary tract catheters)

Clinical Features

Presence of one or more risk factors especially in premature or mechanically ventilated baby with persistent metabolic acidosis should suspect sepsis until prove otherwise hence antibiotics must be used till negative cultures are obtained.

Symptoms are non-specific at first but as the disease progresses start to present according to system affected.

• Early symptoms
  • Irritability
  • Respiratory distress with apneic attacks
  • Lethargy
  • Poor feeding
  • Vomiting
  • Unstable temperature – fever or hypothermia
  • Poor moro and suckling reflexes
• Respiratory
  • Fast breathing
  • Difficulty in breathing (expiratory grunting)
  • FAN and intercostal/sternal retractions
  • Apnea (common in preterm)
  • Cyanosis (reduced oxygen saturation)
• CNS
  • Difficulty sucking
  • Irritability
  • Lethargy
  • Sleepiness
  • Weak OR high-pitched cry
  • Convulsions
  • Hypoactivity
  • Hypotonicity
  • Bulging, tense fontanelle
  • Body temp regulation problems (hypothermia, hyperpyrexia)
• CVS
  • Bradycardia OR Tachycardia
  • Hypotension
  • Prolonged CRT (> 3 sec; blood is redistributed to maintain flow to heart and brain)
• GIT
  • Vomiting
  • DIfficuly sucking
  • Diarrhoea
  • Abdominal distension
  • Hepato-splenomegaly
  • Jaundice
• Skin
  • Jaundice
  • Bluish-grey (cyanosed)
  • Cutis marmorata
  • Pustule
  • Abscess
  • Petechiae
  • Purpura
• Differentials
  • Congenital heart disease
  • Neonatal encephalopathy
  • Metabolic disease
  • Prematurity and associated complications
    • RDS
    • Intraventricular hemorrhage
    • Apnea of prematurity
  • Hypo or hyperthyroidism
  • TTN
  • MAS
  • Hypoglycemia

Investigations

• InvestigationsImportant as most times the clinical presentation may be unclear.
  • CXR: used in cases with symptoms of pneumonia
  • CBC: neutropenia/neutrophilia; Thrombocytopenia
    • Neutropenia has better specificity than neutrophilia as a marker of neonatal sepsis
  • CRP: elevated (low sensitivity for EOS)
  • Procalcitonin: elevated (higher sensitivity for EOS than CRP)
  • Blood culture: negative blood culture does not exclude dx ****
  • CSF culture: done in infants with positive blood culture and clinically considered meningitis. Routinely performed in small children with sepsis.
  • CSF biochemical tests
  • Urinalysis and urine culture: no need in EOS but used in LOS
  • Cell surface markers

Management

• Supportive Treatment
  • Encourage Breastfeeding OR NGT feeds OR IV fluids (if feeding is not feasible)
  • Monitor input/output charts
  • Transfusion of blood products (if indicateed)
  • Oxygen therapy (if respiratory compromise, or SpO2 < 90%)
  • Keep warm if temp < 35.5 C; Expose if temp ≥ 38 C
  • Early transfer to NICU (for critically ill neonate requiring cardiopulmonary support)
  • Encourage KMC
  • Check for and prevent hypoglycemia (RBS)
    • Tx if unable to test in severe neonatal sepsis
• EON Definitive Treatment
  • Penicillin/Ampicillin + Gentamicin (Tx GBS and L. monocytogenes)
  • 3rd and 4th gen cephalosporin (if suspected GN meningitis)
    • Not ceftriaxone, however, as it can lead to hyperbilirubinemia and the serious precipitation of calcium-ceftriaxone crystals.
• LOS Definitive Treatment
  • Vancomycin and Aminoglycoside (Tx CoNS, S. aureus, GN organisms)
  • 3rd gen cephalosporin (if suspected GN meningitis)
  • Meropenem (if patient previously on 3rd gen cephalosporin OR local resistance)
• Preventive Treatment
  • Prophylaxis for Neonatal GBS: Intrapartum IV Penicillin G or Ampicillin 4 hourly until delivery (OR IV cefazolin if mild penicillin reaction, OR Clindamycin if severe penicillin allergy)
    • Maternal GBS coloninzation – Positive Rectal or vaginal swabs at 36 0/7 – 37 6/7 weeks
    • GBS bacteriuria during pregnancy
    • Previous newborn had GBS infection
    • Presence of risk factors (Chorioamnionitis, Fever, Elevated CRP, Premature contractions, PROM)

ETAT+

• When to diagnose Neonatal sepsis
  • Movement only when stimulated
  • Not feeding well on observation
  • Temp > 37 C or < 35.5 C
  • Severe chest wall indrawing
• When to diagnose severe neonatal sepsis
  • Unconscious
  • Hx of convulsions
  • Unable to feed/poor feeding
  • Apnea
  • Unable to cry/high-pitched cry
  • Central cyanosis (SpO2 < 90%, needs O2)
  • Bulging fontanelle
  • Persistent vomiting
• Treatment of Severe neonatal sepsis
  • Admit
  • Oxygen if SpO2 < 90%
  • Keep warm if temp < 35.5 C; expose if temp ≥ 38 C
  • Check for hypoglycemia (Treat hypoglycemia if unable to measure)
  • NGT feeds or IVF
  • Blood and CSF cultures
  • IV crystalline penicillin and Gentamicin (OR cefotaxime and crystalline penicillin) for min 7 days
• Treatment of neonatal sepsis (non-severe)
  • Admit
  • Keep warm if temp < 35.5 C; expose if temp ≥ 38 C
  • Prevent and manage hypoglycemia
  • NGT feeds or IVF
  • IV crystalline penicillin and Gentamicin (OR cefotaxime and crystalline penicillin) for 2 days
  • Change to PO Amoxicillin for 5 days as outpatient if baby is clinically improved and feeding well
• When is Flucloxacillin and Gentamicin preferred in neonatal sepsis
  • Suspected staphylococcal septicaemia
  • Neonates w/ Sx of sepsis and extensive skin pustules/abscess/omphalitis
• When is Metronidazole added in neonatal sepsis
  • Suspected Necrotizing enterocolitis

Duration of treatment

Newborn antibiotic doses for neonates < 7 days

Gentamicin frequency