Neonates: Neonatal Sepsis Flashcards
What is neonatal sepsis?
A life-threatening condition caused by systemic bacterial, viral or fungal infection within the first 28 days of life.
How can neonatal sepsis be further classified?
1) Early onset (occuring in first 48-72 hours of life)
2) Late onset (occuring after the first 48-72 hours of life)
Which organism is the most frequent cause of severe neonatal sepsis?
Group B Streptococcus (GBS)
Give 5 organisms that cause neonatal sepsis
1) Group B streptococcus (GBS)
2) Escherichia coli (e. coli)
3) Listeria
4) Klebsiella
5) Staphylococcus aureus
Why is group B strep a common organism causing neonatal sepsis?
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.
What is given to reduce the risk of transfer if the mother is found to have GBS in their vagina during pregnancy?
Prophylactic Abx
What is neonatal sepsis most commonly caused by (3 ways)?
1) Ascending infection in the mother with chorioamnionitis
2) Perinatally via direct contact in the birth canal
3) Haematogenous spread
What type of bacteria is GBS?
GBS is a gram-positive coccus
Where is GBS found?
It is present in up to 25% of pregnant women’s genital tract
How does the presentation of early vs late onset neonatal sepsis present?
Early –> respiratory distress, pneumonia and septicaemia.
Late –> septicaemia and/or meningitis
What are some risk factors for neonatal sepsis?
1) GBS sepsis in a previous baby
2) Maternal GBS colonisation, bacteriuria or infection in the current pregnancy
3) Prelabour rupture of membranes
4) Prematurity (less than 37 weeks)
5) Prolonged rupture of membranes (PROM) i.e. >18 hours in preterm birth
6) Maternal sepsis, chorioamnionitis or fever > 38ºC
7) RED FLAG –> Parenteral antibiotic treatment given to the woman for confirmed or suspected invasive bacterial infection (such as septicaemia) at any time during labour, or in the 24-hour periods before and after the birth [This does not refer to intrapartum antibiotic prophylaxis]
8) RED FLAG –> Suspected or confirmed infection in another baby in the case of a multiple pregnancy
What are some clinical features of neonatal sepsis?
1) Respiratory distress (most common):
- grunting
- nasal flaring
- use of accessory muscles
- tachypnoea
2) Tachycardia or bradycardia
3) Apnoea
4) Poor/reduced feeding:
- feed refusal
- poor tolerance e.g. vomiting, excessive gastric aspirates and abdominal distension
5) Reduced tone and activity e.g. floppiness
6) Jaundice within 24 hours
7) Seizures (RED FLAG)
8) Temperature:
- term infants: fever
- preterm infants: hypothermic
9) Hypoxia
10) Hypoglycaemia
What are the RED FLAGS suggestive of neonatal infection?
1) Confirmed or suspected sepsis in the mother within 24h of birth
2) Seizures
3) Signs of shock
4) Respiratory distress starting more then 4 hours after birth
5) Need for mechanical ventilation in a term baby
6) Suspected or confirmed infection in a co-twin
Investigations in neonatal sepsis?
1) Blood culture
2) FBC
3) CRP
4) ABG
5) Urine MC&S
6) Lumbar puncture: if concerning features of meningitis e.g. seizures
When should Abx be started in neonatal sepsis?
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.
1st line Abx for suspected or confirmed early onset neonatal sepsis?
IV benzylpenicillin with gentamicin
What should be measured 18–24 hours after neonatal sepsis presentation in babies given antibiotics?
CRP
You can consider stopping the Abx in suspected neonatal sepsis under what conditions?
1) The blood culture is negative, and
2) The initial clinical suspicion of infection was not strong, and
3) The baby’s clinical condition is reassuring with no clinical indicators of possible infection, and
4) The levels and trends of C-reactive protein concentration are reassuring
How long are Abx continued for in neonatal sepsis if:
a) blood cultures are positive
b) CSF is positive
a) 7-10 days
b) 14 days
1st line Abx for suspected or confirmed late onset neonatal sepsis?
Flucloxacillin (or vancomycin) plus gentamicin (IV)
What Abx are given if meningitis is suspected in neonates?
Give amoxicillin and cefotaxime (IV)
Complications of neonatal sepsis?
1) Poor cognitive development
2) Visual or hearing deficits
3) Cerebral palsy
4) Bronchopulmonary dysplasia (BPD)
5) Death
Risk factors for LATE onset neonatal sepsis?
1) Prematurity
2) Low birth weight
3) Invasive procedures (e.g. IV access or intubation
Define late onset neonatal sepsis (LONS)
Sepsis in infants between 72 hours and 28 days corrected gestational age
Which bacteria commonly cause LONS?
1) Coagulase-negative Staphylococci e.g. (most common cause) Staphylococcus epidermidis
2) Group B strep
3) Gram-negative bacteria such as Pseudomonas aeruginosa
4) Enterobacter
5) Fungal species (usually Candida albicans)
What is most route of sepsis in late onset vs early onset
Early onset –> usually due to transmission of pathogens from the mother to the neonate during delivery
Late onset –> usually occurs via the transmission of pathogens from the environment post-delivery e.g. parents or healthcare workers
Risk factors for LONS?
1) Prematurity
2) Mechanical ventilations
3) History of surgery
4) Presence of a central catheter
5) Presence or concern of an infection in another baby when from a multiple birth.
Differentials for LONS?
1) Bowel obstruction
2) Necrotising enterocolitis (NEC)
3) Metabolic disease
4) Cardiac e.g. Congenital cardiac disease
What are 2 ABSOLUTE contraindications to lumbar puncture in neonates?
1) GCS <8
2) Signs of raised ICP
Note - a bulging fontanelle alone, without other signs of raised ICP, is not a contraindication.
Relative contraindications to LP in neonates?
1) Septic shock
2) Respiratory compromise (including apnoeas)
3) New focal neurology or seizures
4) INR > 1.5 or platelets < 50
Investigations in LONS?
1) Blood culture
2) CRP (useful to monitor serially to assess likelihood of infection and monitor response to treatment)
3) Urine microscopy and culture (clean catch or catheter only)
4) Lumbar puncture if safe to do so and there is a strong clinical suspicion of neonatal infection/meningitis
What is the most common cause of severe early-onset (< 7 days) infection in newborn infants?
Group B streptococcus infection
