Management of term infants at increased risk for early onset bacterial sepsis

Question 1

What is early onset neonatal bacterial sepsis?

Answer 1

Sepsis occurring within the first 7d of life

Question 2

What is the incidence of early onset sepsis in Canadian NICU?

Answer 2

0.5%

Question 3

What are the risk factors for early onset sepsis?

Answer 3

1. Maternal intrapartum GBS colonization during the current pregnancy
2. GBS bacteruria at any time during the current pregnancy
3. A previous infant with invasive GBS disease
4. PROM >18h
5. Maternal fever (T>38 degrees C)

Question 4

What is the risk of early onset GBS sepsis in infants born to mother colonized with GBS without intrapartum antibiotic prophylaxis?

Answer 4

1-2%

Question 5

What are the guidelines re: screening pregnant women and GBS?

Answer 5

1. Screen all pregnant women for GBS at 35-37 weeks GA
2. Provide intrapartum antibiotic prophylaxis for all positive screens, if GBS bacteruria, or previous GBS infected infant
3. If GBS status is unknwon IAP should be offered if any risk factors are present
4. Adequate IAP consists of at least one dose given at least 4h prior to birth of Penicillin G 5 million U IV or Ampicillin 2g IV OR Cefazolin 2g IV if mother penicillin allergic but low risk for anaphylaxis
5. Pen-allergic women with high risk for anaphylaxis should be given IV clindamycin if sensitive OR IV vancomycin if resistant or unknown
6. IAP not recommended for c/s before onset of labour when membranes are intact
7. IAP does not reduce incidence of late onset GBS disease

Question 6

What is the rate of meningitis in newborn infants?

Answer 6

0.25-1/1000 live births

Question 7

What percentage of infants with early onset sepsis have negative blood cultures?

Answer 7

8-40%

Question 8

What are the recommendations re: blood culture in EOS?

Answer 8

All infants with suspected EOS should have a blood culture

Question 9

What are the recommendations re: LP in EOS?

Answer 9

Perform LP if:
1. Strong clinical suspicion of EOS
or 2. Signs of meningitis (seizures, bulging fontanelle, irritability, altered neurological status) are present

3. Defer LP if clinically unstable until condition improved
4. Defer LP if resp distress only and close monitoring
5. Must do an LP if blood culture positive

Question 10

What CSF WBC is considered abnormal in term infants?

Answer 10

> 20-25 cells/mm3 (sensitivity 79% and specificity 81% for diagnosing bacterial meningitis)

Question 11

What are the recommendations re: cultures of the urine, gastric aspirate, and body surfaces?

Answer 11

Limited value in evaluation of EOS and not recommended for newly born infants

Question 12

When is a CBC the most helpful at detecting sepsis?

Answer 12

> 4h of life
WBC <5 LR 80.5
ANC 60% LR 10.7

Question 13

What are the recommendations re: CRP?

Answer 13

CRP maybe helpful serially but not as a single value

Question 14

What are other biomarkers that might be helpful in determining EOS?

Answer 14

Procalcitonin

Question 15

What are the recommendations re: newborn unwell term infants?

Answer 15

1. Infants with clinical signs of sepsis (respiratory distress, temperature instability, tachycardia, seizures, hypotonia, lethargy, poor peripheral perfusion, hypotension, acidosis) require prompt investigation, including CBC, blood culture and lumbar puncture, and initiation of empirical intravenous antibiotic therapy. Ampicillin and an aminoglycoside provide coverage for the most common pathogens associated with early onset sepsis (EOS). Infants who have respiratory signs should also have a chest x-ray.
2. Infants with early respiratory signs only and without risk factors for sepsis may be observed for up to 6 h before initiating investigations for sepsis and antibiotic therapy

Question 16

What are the recommendations re: newborn well-appearing term infants?

Answer 16

1. WBC indices (total WBC, ANC, I/T ratio) or a single CRP should not be used routinely as screening or diagnostic tests for EOS, nor to routinely exclude EOS
2. For GBS-positive mothers with adequate intrapartum antibiotic prophylaxis (IAP), no additional risk factors OR mothers who are GBS-negative or GBS-unknown status, with one other risk factor and adequate IAP: Infants do not require investigation or treatment for sepsis. They may be discharged home after 24 h if they remain well, meet other discharge criteria and if parents understand signs of sepsis and when to seek medical care.
3. For GBS-positive mothers with inadequate IAP and no additional risk factors OR mothers who are GBS-negative or GBS-unknown status, with one other risk factor and inadequate IAP: Infants should be examined at birth, observed closely in hospital with vital signs every 3 h to 4 h, and reassessed before discharge home. They may be discharged home after 24 h if they remain well and meet other discharge criteria, providing there is ready access to health care and the parents understand and are able to seek medical care if the infant develops signs of sepsis. Routine investigation or treatment is not required.
4. Multiple risk factors for sepsis and/or chorioamnionitis: Infants should be investigated and treated using an individualized approach that includes consideration of the severity of risk factors and maternal antibiotic therapy. At minimum, infants should have close observation in hospital for at least 24 h with vital signs every 3 h to 4 h and reassessment before discharge. A CBC done after 4 h of age may be helpful; WBC <5 x 109/L and ANC <1.5 x 109/L have the highest positive predictive value. Some infants may warrant investigation and antibiotic therapy

Question 17

What are the recommendations re: well late preterm infants 35-36 weeks GA?

Answer 17

If infants are stable enough to remain with their mother in a mother and baby unit, they can be managed similar to infants ≥37 weeks’ GA, but should be observed in hospital for at least 48 h.