Neonates: Neonatal Sepsis

Question 1

What is neonatal sepsis?

Answer 1

A life-threatening condition caused by systemic bacterial, viral or fungal infection within the first 28 days of life.

Question 2

How can neonatal sepsis be further classified?

Answer 2

1) Early onset (occuring in first 48-72 hours of life)

2) Late onset (occuring after the first 48-72 hours of life)

Question 3

Which organism is the most frequent cause of severe neonatal sepsis?

Answer 3

Group B Streptococcus (GBS)

Question 4

Give 5 organisms that cause neonatal sepsis

Answer 4

1) Group B streptococcus (GBS)

2) Escherichia coli (e. coli)

3) Listeria

4) Klebsiella

5) Staphylococcus aureus

Question 5

Why is group B strep a common organism causing neonatal sepsis?

Answer 5

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.

Question 6

What is given to reduce the risk of transfer if the mother is found to have GBS in their vagina during pregnancy?

Answer 6

Prophylactic Abx

Question 7

What is neonatal sepsis most commonly caused by (3 ways)?

Answer 7

1) Ascending infection in the mother with chorioamnionitis

2) Perinatally via direct contact in the birth canal

3) Haematogenous spread

Question 8

What type of bacteria is GBS?

Answer 8

GBS is a gram-positive coccus

Question 9

Where is GBS found?

Answer 9

It is present in up to 25% of pregnant women’s genital tract

Question 10

How does the presentation of early vs late onset neonatal sepsis present?

Answer 10

Early –> respiratory distress, pneumonia and septicaemia.

Late –> septicaemia and/or meningitis

Question 11

What are some risk factors for neonatal sepsis?

Answer 11

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

Question 12

What are some clinical features of neonatal sepsis?

Answer 12

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

Question 13

What are the RED FLAGS suggestive of neonatal infection?

Answer 13

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

Question 14

Investigations in neonatal sepsis?

Answer 14

1) Blood culture

2) FBC

3) CRP

4) ABG

5) Urine MC&S

6) Lumbar puncture: if concerning features of meningitis e.g. seizures

Question 15

When should Abx be started in neonatal sepsis?

Answer 15

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.

Question 16

1st line Abx for suspected or confirmed early onset neonatal sepsis?

Answer 16

IV benzylpenicillin with gentamicin

Question 17

What should be measured 18–24 hours after neonatal sepsis presentation in babies given antibiotics?

Answer 17

CRP

Question 18

You can consider stopping the Abx in suspected neonatal sepsis under what conditions?

Answer 18

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

Question 19

How long are Abx continued for in neonatal sepsis if:

a) blood cultures are positive
b) CSF is positive

Answer 19

a) 7-10 days
b) 14 days

Question 20

1st line Abx for suspected or confirmed late onset neonatal sepsis?

Answer 20

Flucloxacillin (or vancomycin) plus gentamicin (IV)

Question 21

What Abx are given if meningitis is suspected in neonates?

Answer 21

Give amoxicillin and cefotaxime (IV)

Question 22

Complications of neonatal sepsis?

Answer 22

1) Poor cognitive development
2) Visual or hearing deficits
3) Cerebral palsy
4) Bronchopulmonary dysplasia (BPD)
5) Death

Question 23

Risk factors for LATE onset neonatal sepsis?

Answer 23

1) Prematurity

2) Low birth weight

3) Invasive procedures (e.g. IV access or intubation

Question 24

Define late onset neonatal sepsis (LONS)

Answer 24

Sepsis in infants between 72 hours and 28 days corrected gestational age

Question 25

Which bacteria commonly cause LONS?

Answer 25

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)

Question 26

What is most route of sepsis in late onset vs early onset

Answer 26

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

Question 27

Risk factors for LONS?

Answer 27

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.

Question 28

Differentials for LONS?

Answer 28

1) Bowel obstruction

2) Necrotising enterocolitis (NEC)

3) Metabolic disease

4) Cardiac e.g. Congenital cardiac disease

Question 29

What are 2 ABSOLUTE contraindications to lumbar puncture in neonates?

Answer 29

1) GCS <8

2) Signs of raised ICP

Note - a bulging fontanelle alone, without other signs of raised ICP, is not a contraindication.

Question 30

Relative contraindications to LP in neonates?

Answer 30

1) Septic shock

2) Respiratory compromise (including apnoeas)

3) New focal neurology or seizures

4) INR > 1.5 or platelets < 50

Question 31

Investigations in LONS?

Answer 31

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

Question 32

What is the most common cause of severe early-onset (< 7 days) infection in newborn infants?

Answer 32

Group B streptococcus infection