Neonatal sepsis is a blood infection that occurs in an infant younger than 90 days

old. Early-onset sepsis is seen in the first

week of life. Late-onset sepsis occurs

between days 8 and 89.

Early-onset neonatal sepsis most often appears within 24

hours of birth. The baby gets the infection from the

mother before or during delivery. The following increases an infant's risk of early-onset sepsis:

Group B streptococcus infection during pregnancy Preterm delivery Water breaking (rupture of membranes) that lasts

longer than 24 hours before birth

Infection of the placenta tissues and amniotic fluid (chorioamnionitis)

May occur as early as 5 days but is most common after the first week of life Less association with obstetric complications Usually have an identifiable focus

Most often meningitis or sepsis

Acquired from maternal genital tract or human contact

Primary sepsis
Group B streptococcus Gram-negative enterics (esp. E. coli)

Listeria monocytogenes, Staphylococcus, other

streptococci (entercocci), anaerobes, H. flu

Nosocomial sepsis
Varies by nursery
Staphylococcus epidermidis, Pseudomonas,

Klebsiella, Serratia, Proteus, and yeast are most common

Prematurity and low birth weight Premature and prolonged rupture of membranes Maternal peripartum fever Amniotic fluid problems (i.e. mec, chorio) Resuscitation at birth, fetal distress Multiple gestation Invasive procedures Galactosemia Other factors: sex, race, variations in immune function, hand washing in the NICU

Temperature irregularity (high or low) Change in behavior

Lethargy, irritability, changes in tone

Skin changes
Poor perfusion, mottling, cyanosis, pallor, petechiae, rashes, jaundice

Feeding problems
Intolerance, vomiting, diarrhea, abdominal distension

Cardiopulmonary
Tachypnea, grunting, flaring, retractions, apnea, tachycardia, hypotension

Metabolic
Hypo or hyperglycemia, metabolic acidosis

Cultures
Blood
Confirms sepsis 94% grow by 48 hours of age

Urine
Dont need in infants <24 hours old because UTIs are exceedingly rare in this age group

CSF
Controversial May be useful in clinically ill newborns or those with positive blood cultures

White blood cell count and differential

Neutropenia can be an ominous sign I:T ratio > 0.2 is of good predictive value Serial values can establish a trend

Platelet count
Late sign and very nonspecific

Acute phase reactants

CRP rises early, monitor serial values(10 mg/L) ESR rises late

Other tests: bilirubin, glucose, sodium

CXR
Obtain in infants with respiratory symptoms Difficult to distinguish GBS or Listeria

pneumonia from uncomplicated RDS

Renal ultrasound and/or VCUG in infants with accompanying UTI

Babies in the hospital and those younger than 4 weeks old are started on antibiotics before lab results are back. (Lab results may take 24-72 hours.) This practice has saved many lives. Older babies may not be given antibiotics if all lab results are within normal limits. Instead, the child may be followed closely on an outpatient basis. Babies who do require treatment will be admitted to the hospital for monitoring.

Antibiotics
Primary sepsis: ampicillin and gentamicin Nosocomial sepsis: vancomycin and

gentamicin or cefotaxime Change based on culture sensitivities Dont forget to check levels

Respiratory

Cardiovascular Hematologic CNS

Oxygen and ventilation as necessary Support blood pressure with volume expanders and/or pressors Treat DIC with FFP and/or cryo Treat seizures with phenobarbital Watch for signs of SIADH (decreased UOP, hyponatremia) and treat with fluid restriction Treat hypoglycemia/hyperglycemia and metabolic acidosis

Metabolic