for Neonatal Sepsis
|Reviewed by Clinical
- Bacterial sepsis is a major problem in the newborn unit.
- The incidence of sepsis is higher in preterm infants, especially the
very low birthweight infant (<1500g).
- Common organisms identified are coagulase negative Staphylococci,
Staphylococcus aureus, Streptococcus agalactiae (Group B Streptococcus)
and Escherichia coli.
- Other important pathogens include Listeria monocytogenes,
Streptococcus pneumoniae, Haemophilus influenza and other Gram-negative
- The clinical presentation of sepsis in the newborn is often
non-specific; however, there may be an acute deterioration.
|Early Onset Sepsis
(infection occurring in the first 5 days of life)
(infection occurring after 5 days of age)
|Exposure to bacteria can occur:
- Before delivery due to infected amniotic fluid or occasionally
following maternal sepsis
- During delivery when contact with organisms in the vagina can
- After delivery following exposure to organisms in the infants
|Usually due to:
- Nosocomial infection, organisms acquired from the environment
- Coagulase negative Staphylococci are the most common causative
- VLBW infants with indwelling catheters, central lines, chest
drains etc are at particular risk
- Antibiotics should be considered in any baby with signs of sepsis,
particularly in the presence of risk factors.
- Risk factors may be an indication for investigation but are not in
themselves an indication for antibiotics if the baby is born at term and
is clinically well.
- If there are any doubts a senior member of staff should be
- Prolonged rupture of membranes (>18 hours).
- Prematurity (especially in association with
- Preterm labour with no adequate explanation
- Fetal distress without adequate explanation
(fetal heart rate abnormalities especially fetal tachycardia, passage of
- Maternal fever or other evidence of infection.
- Foul smelling amniotic fluid or malodorous baby
- Indwelling vascular catheter
Sepsis in the Newborn
- Fever, hypothermia and/or temperature
- Respiratory distress.
- Apnoea and bradycardia
- Cyanotic episodes
- Tachycardia, hypotension
- Lethargy, irritability, poor feeding.
- Unexplained high/low or unstable blood sugars
- Abdominal distension and bile-stained aspirates
- Unexplained jaundice
- Umbilical flare, skin rashes
What Investigations Should be Performed?
- Full blood count.
- Differential white cell count (Normal WBC
10-30,000 x 109/L) and percentage left shift (immature
neutrophils/total neutrophil count).
- If >20% this is moderately predictive
- A low WCC especially with neutropenia is
also suspicious of sepsis.
- Blood cultures.
- Chest radiograph
- A C-Reactive Protein (CRP) may
be indicated. CRP is most useful as a trend, rather than as a diagnostic
- On occasion, skin/wound swabs and (very -rarely) gastric aspirate (at
- CSF may be needed in some cases - discuss with specialist.
The following investigations may need to be
considered depending on the organism isolated.
Early onset infection: LP is indicated if the organism is Group
B strep or E coli or if infant severely unwell.
Late onset sepsis:
addition to the above consider
- Blood culture taken through central line.
- Lumbar puncture and CSF for
- Urine by suprapubic aspirate
Use in Suspected Sepsis
First five days
After first five days
Start amoxycillin and
and amikacin in all babies
- Almost all Coag negative Staphylococcus is sensitive to
amikacin but resistant to gentamicin.
- Flucloxacillin is used at
present because of an increased number of Staphylococcus aureus isolates
within the unit.
Add amoxycillin if specific cover
for Enterococci, Strep fecaelis (suspected
NEC), Listeria or
Group B Streptococcus is needed.
- Review clinical progress and microbiology results at 36 hours.
- If cultures negative
consider stopping therapy.
- Continue therapy if cultures positive or sepsis
- Add metronidazole
if suspicion of anaerobic infection (e.g. intra-abdominal sepsis,
NEC). If abdominal
infection/NEC beyond 5 days use amoxicillin in preference to flucloxacillin
- Consider vancomycin
for coagulase negative Staphylococcal sepsis, especially if infant unwell or
central line infection with line staying in. Discuss with specialist
neonatal meningitis. Discuss with specialist first.
- Consider cefuroxime or piptaz for ventilator-associated pneumonia
Duration (days) of therapy
Urinary Tract Infection
(depending on organism isolated)