Neonatal Sepsis

Onset
Neonatal sepsis may be categorized as
early-onset or late-onset
Of newborns with early-onset sepsis:
o 85% present within 24 hours
o 5% present at 24-48 hours
o a smaller percentage present within 48-72 hours

Onset is most rapid in premature

neonates.

Early-Onset Sepsis
Transplacental
infection
or
an
ascending infection from the
cervix may be caused by organisms
that
colonize
the
mothers
genitourinary tract.
The
neonate
acquires
the
microorganisms as it passes through
the colonized birth canal at delivery.

Early-Onset Sepsis

The
most commonly
microorganisms
Group BStreptococcus(GBS)
associated with early-onset infection
E. coli
include the following:
Coagulase-negativeStaphylococcus
H. Influenza
Listeria monocytogenes

Early-Onset Sepsis
Trends in the epidemiology of earlyonset sepsis show a decreasing
incidence of GBS disease. This
can
be
attributed
to
the
implementation of a prenatal
screening
and
treatment
protocol for GBS.

Case Study
In a 2009 study done in Houston, Texas involving
4696 women
showed that Intrapartum
Antibiotic Prophylaxis was effective in
interrupting mother-to-newborn transmission
of GBS.
However, ~10% of prenatally GBS-negative women
were positive during labor and missed IAP while
~50% of prenatally GBS-positive women were
negative during labor and received IAP.
These findings emphasize the need for rapid
diagnostics during labor.

Late-Onset Sepsis
Late-onset sepsis occurs at 4-90 days of life and
is acquired from the caregiving environment.
Organisms that have been implicated in
causing LOS include the following:

o CoagulasenegativeStaphylococcus
o Staphlococcus aureus
o E coli
o Klebsiella
o Pseudomonas
o Enterobacter

o
o
o
o
o

Candida
GBS
Serratia
Acinetobacter
Anaerobes

Late-Onset Sepsis
Trends in late-onset sepsis show an increase in
coagulase-negative streptococcal sepsis; most
of these isolates are susceptible to first-generation
cephalosporins.
The infants skin, respiratory tract, conjunctivae,
gastrointestinal (GI) tract, and umbilicus may
become colonized from the environment, and such
colonization to the possibility of late-onset sepsis
from invasive microorganisms.
Vectors for such colonization may include vascular
or urinary catheters, other indwelling lines, or
contact with caregivers who have bacterial
colonization.

Signs and Symptoms

Common signs:
o Diminished spontaneous activity
o Feeding intolerance
o Apnea, respiratory distress
o Tachycardia or bradycardia
o Hypotension
o Poor perfusion with pallor
o Temperature instability (hypo or hyperthermia)

Signs and Symptoms

Specific signs:
o Meningitis, encephalitis, or brain abscess
Coma, Seizures, Opisthotonos

o Omphalitis
Periumbilical erythema, discharge, or bleeding
without a hemorrhagic diathesis

o Peritonitis or necrotizing enterocolitis

Unexplained abdominal distention, bloody diarrhea,
fecal leukocytes
*Pneumoniais more common in early-onset sepsis, whereas meningitis
and bacteremia are more common in late-onset sepsis.

Signs and Symptoms

Specific signs:
o Early-onset GBS and L. monocytogenes
Respiratory distress

o Osteomyelitis or pyogenic arthritis

Decreased spontaneous movement or
extremity, swelling, warmth, erythema,
tenderness over a joint

Later complications of
sepsis

Respiratory Failure
Pulmonary Hypertension
Cardiac Failure
Shock
Renal failure
Liver dysfunction
Cerebral Edema or thrombosis
Adrenal hemorrhage and/or insufficiency
DIC

Treatment
When neonatal sepsis is suspected,
treatment should be initiated
immediately because of the
neonates relative
immunosuppression.
Begin antibiotics as soon as
diagnostic tests are performed

Treatment
EOS
Initial therapy should include ampicillin or
penicillin G plus an aminoglycoside
Cefotaxime may be added to or substituted for
aminoglycoside if meningitis is suspected
If foul-smelling amniotic fluid is present at
birth, therapy for anaerobes, clindamycin,
metronidazole should be added

Treatment
LOS (in a previously well neonate)
Ampicillin plus gentamicin or ampicillin plus
cefotaxime If gram ve meningitis is
suspected, ampicillin, cefotaxime and
aminoglycoside
Late-onset sepsis in hospital-acquired:
o Vancomycin plus aminoglycoside
o If P. aeruginosa is prevalent in nursery,
ceftazidime is used instead of aminoglycoside

Treatment
Supportive therapy:
Respiratory and hemodynamic management
Other Treatments:
Exchange transfusion in severely ill (hypotensive, metabolic
acidosis)
Fresh frozen plasma
o Can help reverse heat-stable and heat-labile opsonin deficiencies
that occur in low birth weight infants

Granulocyte transfusions have been used but have not

improved outcome significantly
IV immune globulin given at birth may prevent sepsis in
high-risk low birth weight infants

References
American Academy of Pediatrics Committee on
Infectious Diseases and Committee on Fetus and
Newborn. Policy Statement: Recommendations for
the Prevention of Perinatal Group B Streptococcal
(GBS) Disease.Pediatrics
Verani JR, McGee L, Schrag S. Prevention of
Perinatal Group B Streptococcal Disease, Revised
Guidelines from CDC, 2010.Morbidity and Mortality
Weekly Report.
Stoll et al. Early onset neonatal sepsis: the burden
of group B streptococcal andE. coliPediatrics.

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