for Neonatal Sepsis
|Reviewed by Carl
- Bacterial sepsis is a major
problem in the newborn unit. Approximately 10% of all neonates admitted to
NICU are treated with antibiotics for suspected sepsis.
- A bacterial cause is found in
less than 10% of these infants (1-5 per 1000 live births).
- The incidence of sepsis is
higher in preterm infants, especially the very low birthweight infant
- Common organisms identified
are coagulase negative Staphylococci (28%*), Staphylococcus aureus
(19%*), Streptococcus agalactiae (10%*) and Escherichia coli
- Other important pathogens
include Listeria monocytogenes, Streptococcus pneumoniae, Haemophilus
influenza and other Gram-negative organisms (total of 20%*).
- The clinical presentation of
sepsis in the newborn is often non-specific; however, there may be an acute
* Figures for blood stream
infections within NICU at NWH 1998.
|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
should Antibiotics be Given?
- 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 - particularly a full blood count - but are not in themselves
an indication for antibiotics if the baby is born at term and is clinically
- This is not a complete list and if there are
any doubts a more senior member of staff should be consulted.
- Prolonged rupture of membranes (>24 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
- 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
- On occasion, skin/wound swabs and gastric
aspirate (at birth only).
- CSF may be needed in some cases - discuss with
The following investigations may need to be
considered depending on the organism isolated.
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 48 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,
- Consider vancomycin for coagulase
negative Staphylococcal sepsis, especially if infant unwell or central
line infection with line staying in. Discuss
with specialist first.
- Change to
neonatal meningitis. Discuss with
Duration (days) of therapy
Urinary Tract Infection
(depending on organism isolated)
||Neonatal sepsis and meningitis. Philip AGS. GK
Hall Medical Publishers. Boston 1985. ISBN 0-8161-2253-9.
||Neonatal Sepsis; progress in
diagnosis and management. St Geme III JW. Polin RA. New Ethicals 1989; 25(6);
133-41(part 1) and 25(7); 109-31(part 2).