Neonatal Sepsis

Question 1

What is neonatal sepsis?

Answer 1

Neonatal sepsis is caused by infection in the neonatal period. It potentially results in significant morbidity and mortality for the affected infant, particularly if treatment is delayed.

Question 2

What is early onset neonatal sepsis (EONS)?

Answer 2

Early onset neonatal sepsis (EONS) is defined as sepsis occurring within the first 48-72 hours of life.

Question 3

What organisms commonly cause EONS?

Answer 3

• Group B streptococcus (GBS)
• Escherichia coli (e. coli)
• Listeria
• Klebsiella
• Staphylococcus aureus

Question 4

What organisms commonly cause late onset neonatal sepsis?

Answer 4

• Staphylococcus aureus = commonest
• Staph epidermidis
• E. coli
• Pseudomonas
• Klebsiella

Question 5

What is the most common organism causing neonatal sepsis?

Answer 5

Group B streptococcus (GBS).

Question 6

Why does Group B streptococcus (GBS) cause neonatal sepsis?

Answer 6

This is a common bacteria found in the vagina. It does not cause any problems for the mother, but can be transferred to the baby during labour and cause neonatal sepsis. Prophylactic antibiotics during labour are used to reduce the risk of transfer if the mother is found to have GBS in their vagina during pregnancy.

Question 7

What are the risk factors for neonatal sepsis?

Answer 7

• Vaginal GBS colonisation
• GBS sepsis in a previous baby
• Maternal sepsis, chorioamnionitis or fever > 38ºC
• Prematurity (less than 37 weeks)
• Early (premature) rupture of membrane
• Prolonged rupture of membranes (PROM)

Question 8

What are the clinical features of neonatal sepsis?

Answer 8

• Fever
• Reduced tone and activity
• Poor feeding
• Respiratory distress or apnoea
• Vomiting
• Tachycardia or bradycardia
• Hypoxia
• Jaundice within 24 hours
• Seizures
• Hypoglycaemia

Question 9

What are the red flags for neonatal sepsis?

Answer 9

• 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 a multiple pregnancy

Question 10

What investigations should be ordered for neonatal sepsis?

Answer 10

Full blood count, C- Reactive Protein (CRP) and blood cultures are taken initially before commencing antibiotics. If there is any obvious source e.g. foul smelling urine, or an eye with purulent discharge, relevant swabs/cultures should be taken. The CRP is then repeated at 18-24 hours.

A lumbar puncture (LP) may be performed to obtain a cerebrospinal fluid sample (CFS) before starting antibiotics if it is thought safe to do so and there is a strong clinical suspicion of infection, or there are clinical symptoms or signs suggesting meningitis. If performing the LP would unduly delay starting antibiotics, perform it as soon as possible after starting antibiotics.

LP may also be considered if the first or repeat CRP is raised (>10mg/L), the blood culture is positive or the baby does not respond satisfactorily to antibiotics. Asymptomatic babies on postnatal ward/ transitional care unit with CRP ≤60mg/L do not require a routine LP but should be reviewed by a middle grade doctor.

Question 11

Briefly describe the NICE guidelines for treating presumed sepsis

Answer 11

NICE guidelines:

• If there is one risk factor or clinical feature, monitor the observations and clinical condition for at least 12 hours
• If there are two or more risk factors or clinical feature of neonatal sepsis start antibiotics
• Antibiotics should be started if there is a single red flag
• Antibiotics should be given within 1 hour of making the decision to start them
• Blood cultures should be taken before antibiotics are given
• Check a baseline FBC and CRP
• Perform a lumbar puncture if infection is strongly suspected or there are features of meningitis (e.g. seizures)

Question 12

What antibiotics are used to treat neonatal sepsis?

Answer 12

Always check your local antibiotic policy. The NICE guidelines (2012) recommend benzylpenicillin and gentamycin as first line antibiotics.

Alternatively a third generation cephalosporin (e.g. cefotaxime) may be given as an alternative in lower risk babies.

Question 13

Briefly describe the ongoing management of a child with neonatal sepsis

Answer 13

Check the CRP again at 24 hours and check the blood culture results at 36 hours:

• Consider stopping the antibiotics if the baby is clinically well, the blood cultures are negative 36 hours after taking them and both CRP results are less than 10.

Check the CRP again at 5 days if they are still on treatment:

• Consider stopping antibiotics if the baby is clinically well, the lumbar puncture and blood cultures are negative and the CRP has returned to normal at 5 days.
• Consider performing a lumbar puncture if any of the CRP results are more than 10.

Question 14

What differentials should be considered for neonatal sepsis?

Answer 14

• Transient Tachypnoea of the newborn (TTN)
• Surfactant deficient lung disease / respiratory distress syndrome (RDS)
• Meconium Aspiration
• Haemolytic Disease of the Newborn

Question 15

How does neonatal sepsis and transient tachypnoea of the newborn (TTN)?

Answer 15

TTN in term babies, causes tachypnoea and increased work of breathing.

Question 16

How does neonatal sepsis and surfactant deficient lung disease / respiratory distress syndrome (RDS) differ?

Answer 16

In preterm infants can cause tachypnoea and increased work of breathing.

Question 17

How does neonatal sepsis and meconium aspiration differ?

Answer 17

Can cause the baby to be born in poor condition, with respiratory distress, and may require intubation. Meconium aspiration can cause a rise in CRP.

Question 18

How does neonatal sepsis and haemolytic disease of the newborn differ?

Answer 18

Can present with jaundice within the first 24 hours of life.

Question 19

What are the complications of neonatal sepsis?

Answer 19

Overall mortality rates in late preterm and term infants from sepsis is 2-4%, with the rate being higher in babies with low birth weight and those who are preterm. Neonates with EONS from E.Coli have mortality rates of 6-10%. Mortality rates for term babies with early onset GBS sepsis are around 2-3%.