Neonatal Sepsis

Neonatal sepsis
Neonatal sepsis is a type of neonatal infection and specifically refers to the

presence in a newborn baby of a bacterial blood stream infection (BSI) (such as
meningitis, pneumonia, pyelonephritis, or gastroenteritis) in the setting of fever.
Older textbooks may refer to neonatal sepsis as "sepsis neonatorum". Criteria
with regards to hemodynamic compromise or respiratory failure are not useful
clinically because these symptoms often do not arise in neonates until death is
imminent and unpreventable.
Types:-
Neonatal sepsis is divided into two categories:-
 Early-onset sepsis (EOS)
 Late-onset sepsis (LOS).
Early onset sepsis
EOS refers to sepsis presenting in the first 7 days of life (although some refer to
EOS as within the first 72 hours of life),
Late onset sepsis:-
LOS referring to presentation of sepsis after 7 days (or 72 hours, depending on the
system used).
Neonatal sepsis is the single most important cause of neonatal death in hospital
as well as community in developing country.
It is difficult to clinically exclude sepsis in newborns less than 90 days old that
have fever (defined as a temperature > 38 °C (100.4 °F). Except in the case of
obvious acute viral bronchiolitis, the current practice in newborns less than 30
days old is to perform a complete workup including complete blood count with
differential, blood culture, urinalysis, urine culture, and cerebrospinal fluid (CSF)
studies and CSF culture, admit the newborn to the hospital, and treat empirically
for serious bacterial infection for at least 48 hours until cultures are
demonstrated to show no growth. Attempts have been made to see whether it is
possible to risk stratify newborns in order to decide if a newborn can be safely
monitored at home without treatment despite having a fever. One such attempt
is the Rochester criteria.
Risk factors
A study performed at Strong Memorial Hospital in Rochester, New York, showed
that infants ≤ 60 days old meeting the following criteria were at low-risk for
having a serious bacterial illness:
 generally well-appearing
 previously healthy
o full term (at ≥37 weeks gestation)
o no antibiotics perinatally
o no unexplained hyperbilirubinemia that required treatment
o no antibiotics since discharge
o no hospitalizations
o no chronic illness
o discharged at the same time or before the mother
 no evidence of skin, soft tissue, bone, joint, or ear infection
 White blood cells (WBCs) count 5,000-15,000/mm3
 absolute band count ≤ 1,500/mm3
 urine WBC count ≤ 10 per high power field (hpf)
 stool WBC count ≤ 5 per high power field (hpf) only in infants with diarrhea
Those meeting these criteria likely do not require a lumbar puncture, and are felt
to be safe for discharge home without antibiotic treatment, or with a single dose
of intramuscular antibiotics, but will still require close outpatient follow-up.
One risk for Group B streptococcal infection (GBS) is Preterm rupture of
membranes. Screening women for GBS (via vaginal and rectal swabbing) and
treating culture positive women with intrapartum chemoprophylaxis is reducing
the number of neonatal sepsis caused by GBS.
Signs and symptoms

The signs of sepsis are non-specific and include:
 Body temperature changes
 Breathing problems
 Diarrhea
 Low blood sugar (hypoglycemia)
 Reduced movements
 Reduced sucking
 Seizures
 Bradycardia
 Swollen belly area
 Vomiting
 Yellow skin and whites of the eyes (jaundice)
A heart rate above 160 can also be an indicator of sepsis, this tachycardia can
present up to 24 hours before the onset of other signs.
Diagnosis
Neonatal sepsis screening:
1. DLC (differential leukocyte count) showing increased numbers of
polymorphs.
2. DLC: band cells > 20%.
3. increased haptoglobins.
4. micro ESR (Erythrocyte Sedimentation Rate) titer > 15mm.
5. gastric aspirate showing > 5 polymorphs per high power field.
6. newborn CSF (Cerebrospinal fluid) screen: showing increased cells and
proteins.
7. suggestive history of chorioamnionitis, PROM (Premature rupture of
membranes), etc...
Culturing for microorganisms from a sample of CSF, blood or urine, is the gold
standard test for definitive diagnosis of neonatal sepsis. This can give false
negatives due to the low sensitivity of culture methods and because of
concomitant antibiotic therapy. Lumbar punctures should be done when possible
as 10-15% presenting with sepsis also have meningitis, which warrants an
antibiotic with a high CSF penetration.
CRP is not very accurate in picking up cases.
Treatment and Prevention

Note that, in neonates, sepsis is difficult to diagnose clinically. They may be
relatively asymptomatic until hemodynamic and respiratory collapse is imminent,
so, if there is even a remote suspicion of sepsis, they are frequently treated with
antibiotics empirically until cultures are sufficiently proven to be negative. In
addition to fluid resuscitation and supportive care, a common antibiotic regimen
in infants with suspected sepsis is a beta-lactam antibiotic (usually ampicillin) in
combination with an aminoglycoside (usually gentamicin) or a third-generation
cephalosporin (usually cefotaxime—ceftriaxone is generally avoided in neonates
due to the theoretical risk of kernicterus.) The organisms which are targeted are
species that predominate in the female genitourinary tract and to which neonates
are especially vulnerable to, specifically Group B Streptococcus, Escherichia coli,
and Listeria monocytogenes (This is the main rationale for using ampicillin versus
other beta-lactams.) Of course, neonates are also vulnerable to other common
pathogens that can cause meningitis and bacteremia such as Streptococcus
pneumoniae and Neisseria meningitidis. Although uncommon, if anaerobic
species are suspected (such as in cases where necrotizing enterocolitis or
intestinal perforation is a concern, clindamycin is often added.
Granulocyte-macrophage colony stimulating factor (GM-CSF) is sometimes used
in neonatal sepsis. However, a 2009 study found that GM-CSF corrects
neutropenia if present but it has no effect on reducing sepsis or improving
survival.
Trials of probiotics for prevention of neonatal sepsis have generally been too
small and statistically underpowered to detect any benefit, but a randomized
controlled trial that enrolled 4,556 neonates in India reported that probiotics
significantly reduced the risk of developing sepsis. The probiotic used in the trial
was Lactobacillus plantarum.

Neonatal Sepsis

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Neonatal sepsis

Neonatal sepsis is a type of neonatal infection and specifically refers to the

Signs and symptoms

Treatment and Prevention

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