Neonatal Sepsis

Table Of Contents

Overview

Suspected sepsis: Presence of sepsis risk factors in the baby, or findings sugesting sepsis ni f/u regardless of whether there are Sx or not.

Clinical sepsis: Clinical Sx and lab findings are presents, but fail to show causative organisms

Proven sepsis: Clinical Sx and lab findings are resent and demonstrate organisms in cultures taken from sterile field

Sepsis Criteria: SIRS + Source of infection (susepcted or present)

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

Neonatal sepsis	Time of Onset	Etiology
Early-onset Neonatal Sepsis (EOS)	≤ 7 days after deliver	Transmission from geniourinary tract to newborn or fetus
Late-onset neonatal sepsis (LOS)	≥ 7 days – 60 days of life	Transmission from contact with enviroment (healthcare workers, caregivers)

Signs and symptoms are non-specific. May be multisystemic or focal.

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 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

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 il neonated 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)
LOS Definitive Treatment
- Vancomycin and Aminoglycoside (Tx CoNS, S. aureus, GN organisms)
- 3rd gen cephalosporin (if suspected GN meningitis)
- Meropenem (if pt previously on 3rd gen cephalosporin OR local resistance)
Preventative Treatment
- Prophylaxis for Neonatal GBS: Intrapartum IV Penicilin 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)

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
Tretament 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 septiemia
- Neonates w/ Sx of sepsis and extesive skin pustules/abscess/omphallitis
When is Metronidazole added in neonatal sepsis
- Suspected Necrotizing enterocolitis

Duration of treatment

Condition	Duration of Tx
Breastfeeding well	2 days, PO Tx to complete 5 days
Skin infection	3 days, PO Tx to complete 5 days
Clinical or radiological Pneumonia	minimum 5 days
Severe neonatal sepsis	minimum 7 days
GN bacteremia	10 – 14 days
< 32/40 GA	10 – 14 days
Uncomplicated GBS meningitis	minimum 14 days, extend duration if focal complications
GN bacterial meningitis	minimum 21 days; or for another 2 weeks after first negative CSF culture

Newborn antibiotic doses for neonates < 7 days

Antibiotic	Dose	Frequency	Route
Penicillin	50,000 IU/kg	12 hourly, 6hrly > 7 days	IV/IM
Ampicillin/Flucloxacillin	50mg/kg	12 hourly	IV/IM
Gentamicin	3mg/kg < 2kg; 5mg/kg ≥ 2kg;	24 hourly	IV/IM
Ceftriaxone	50mg/kg	24 hourly	IV/IM
Metronidazole	7.5 mg/kg	12 hourly	IM
Oral Amoxicillin	50mg/kg (100mg/kg/day)	12 hourly	PO

Gentamicin frequency