Neonatal Sepsis and observation

Guideline – GL 380

Approval and Authorisation

Approved by Job Title Date
Paediatric Clinical Governance Chair, Paediatric Clinical 19/1/18
Governance Committee

Change History
Version Date Author Reason
2.0 Aug 2009 N Pritchard Update of expired Guideline
2.1 Aug 2011 G Boden Update of expired Guideline
2.2 July 2013 P de Halpert Revised in line with NICE
2.3 March 2016 P de Halpert Reauthorized
2.4 Jan 2018 P de Halpert Revised in line with RCOG

Author: P de Halpert Date: Jan 2018

Job Title: Consultant Paediatrician Review Date: Jan 2020
Policy Lead: Urgent Care Group Director Version: 2.4 ratified 19/1/18
Location: Corporate Governance Shared Drive – GL380
1
Paediatric Guidelines – Neonatal sepsis & observation (GL380) January 2018

The approach to assessing and treating Early onset neonatal sepsis

uses a scoring system that identifies risk factors and clinical indicators.
There are ‘red-flag’ and ‘non-red flag’ indicators for both and are listed
below.

RED FLAG INDICATORS

Risk Factors tick

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]

Suspected or confirmed infection in another baby in the case of a multiple

pregnancy

Clinical Indicators

Respiratory distress starting more than 4 hours after birth

Seizures

Need for mechanical ventilation in a term baby

Signs of shock

IF ANY RED FLAG FEATURES THEN PERFORM INVESTIGATIONS AND

START ANTIBIOTIC TREATMENT WITHIN 1 HOUR

Author: P de Halpert Date: Jan 2018

Job Title: Consultant Paediatrician Review Date: Jan 2020
Policy Lead: Urgent Care Group Director Version: 2.4 ratified 19/1/18
Location: Corporate Governance Shared Drive – GL380
2
 Paediatric Guidelines – Neonatal sepsis & observation (GL380) January 2018

Risk Factors tick

 Invasive group B streptococcal infection in a previous baby

 Maternal group B streptococcal colonisation, bacteriuria or infection in the current pregnancy

 Term Prelabour rupture of membranes ( >24 hours before established (4cm dilated) labour)

 Preterm birth following spontaneous labour (before 37 weeks' gestation)

 Suspected or confirmed rupture of membranes for more than 18 hours in a preterm birth

 Intrapartum fever higher than 38.0°C, or confirmed or suspected chorioamnionitis

Clinical Indicators

 Altered behaviour or responsiveness

 Altered muscle tone (for example, floppiness)

 Feeding difficulties (for example, feed refusal)

 Feed intolerance, including vomiting, excessive gastric aspirates and abdominal distension

 Abnormal heart rate (bradycardia or tachycardia)

 Signs of respiratory distress

 Hypoxia (for example, central cyanosis or reduced oxygen saturation level)

 Jaundice within 24 hours of birth

 Apnoea

 Signs of neonatal encephalopathy

 Need for cardio–pulmonary resuscitation

 Need for mechanical ventilation in a preterm baby

 Persistent fetal circulation (persistent pulmonary hypertension)

 Temperature abnormality (lower than 36°C or higher than 38°C) unexplained by environmental
factors

 Unexplained excessive bleeding, thrombocytopenia, or abnormal coagulation (INR >2.0)

 Oliguria persisting beyond 24 hours after birth

 Altered glucose homeostasis (hypoglycaemia or hyperglycaemia)

 Metabolic acidosis (base deficit of 10 mmol/litre or greater) in neonate (not cord)

 Local signs of infection (for example, affecting the skin or eye)

TOTAL NUMBER OF INDICATORS

Author: P de Halpert Date: Jan 2018

Job Title: Consultant Paediatrician Review Date: Jan 2020
Policy Lead: Urgent Care Group Director Version: 2.4 ratified 19/1/18
Location: Corporate Governance Shared Drive – GL380
3
Paediatric Guidelines – Neonatal sepsis & observation (GL380) January 2018

NON-RED FLAG INDICATORS

IF 2 OR MORE ‘NON RED FLAG’ RISK FACTORS OR CLINICAL INDICATORS THEN
PERFORM INVESTIGATION AND START ANTIBIOTIC TREATMENT WITHIN 1 HOUR

In babies without red flags and only one risk factor or one clinical indicator, using clinical
judgment, consider:
 whether it is safe to withhold antibiotics, and
 whether it is necessary to monitor the baby's vital signs and clinical condition – if
monitoring is required continue it for at least 12 hours (at 0, 1 and 2 hours
and then 2-hourly for 10 hours) using the Baby Observation Chart - any
abnormal values must be acted upon.

INVESTIGATIONS
Before starting antibiotics:
 CRP
 Blood cultures
 Lumbar puncture if it is thought safe to do so AND:
o there is a strong clinical suspicion of infection, or
o there are clinical symptoms or signs suggesting meningitis.
o NB: If performing the lumbar puncture would unduly delay starting
antibiotics, perform it as soon as possible after starting antibiotics.
Do not routinely perform (if not clinically indicated):
 Urine MC&S
 Skin swab

Specific infections:
 Purulent eye discharge – eye swabs, including for Chlamydia, gonococcus. Start
systemic antibiotic treatment for possible gonococcal infection while awaiting the
swab microbiology results
 Any clinical signs of umbilical infection - purulent discharge or signs of
periumbilical cellulitis (e.g., redness, increased skin warmth or swelling). Perform a
blood culture, take a swab sample for microscopy and culture, and start antibiotic
treatment with IV Flucloxacillin and Cefotaxime.

During antibiotics:
 Repeat CRP 18-24 hours after presentation
 Consider performing a lumbar puncture in a baby who did not have a lumbar
puncture at presentation who is receiving antibiotics, if it is thought safe to do so
and if the baby:
o Has a CRP >25 mg/l
o has a positive blood culture, or
o does not respond satisfactorily to antibiotic treatment
Author: P de Halpert Date: Jan 2018
Job Title: Consultant Paediatrician Review Date: Jan 2020
Policy Lead: Urgent Care Group Director Version: 2.4 ratified 19/1/18
Location: Corporate Governance Shared Drive – GL380
4
Paediatric Guidelines – Neonatal sepsis & observation (GL380) January 2018

Normal CSF values

3 3
RBC/mm WBC/mm Protein g/l Glucose mmol/l
Preterm < 7 days 30 (0-333) 9 (0-30) 1 ( 0.5-2.9) 3
Preterm >7 days 30 12 (2-70) 0.9 (0.5-2.6) 3
Term <7 days 9 (0-50) 5 (0-30) 0.6 (0.3-2.5) 3
Term > 7 days <10 3 (0-10) 0.5 ( 0.2-0.8) 3
Bloody Tap
Calculate the ratio WBC to RBC allow 1:500 if unsure treat for meningitis

ANTIBIOTIC TREATMENT
First choice antibiotics for empirical treatment for suspected infection are benzylpenicillin
and Cefotaxime
 Benzylpenicillin 50mg/kg every 12 hours
o Consider shortening the dose interval to 8-hourly based on clinical
judgement (e.g., if the baby appears very ill)
 Cefotaxime 50 mg/kg every 12 hours
o For further information on dosing and reconstitution please refer to the
neonatal formulary

DURATION OF TREATMENT
In babies given antibiotics because of risk factors for infection or clinical indicators of
possible infection consider stopping the antibiotics at 36 hours if:
 the blood culture is negative, and
 the initial clinical suspicion of infection was not strong, and
 the baby's clinical condition is reassuring with no clinical indicators of possible
infection, and
 the levels and trends of C-reactive protein concentration are reassuring.

The usual duration of antibiotic treatment should be 7 days for babies with:
 positive blood culture, and
 those with a negative blood culture but in whom there has been strong suspicion of
sepsis

Consider continuing antibiotic treatment for more than 7 days if:

 the baby has not yet fully recovered, or
 this is advisable, based on the pathogen identified on blood culture (seek expert
microbiological advice if necessary).

If continuing antibiotics for longer than 36 hours despite negative blood

cultures, review the baby at least once every 24 hours. On each occasion, consider
whether it is appropriate to stop antibiotic
treatment, taking account of:
 the level of initial clinical suspicion of infection
 the baby's clinical progress and current condition, and
 the levels and trends of CRP concentration

Author: P de Halpert Date: Jan 2018

Job Title: Consultant Paediatrician Review Date: Jan 2020
Policy Lead: Urgent Care Group Director Version: 2.4 ratified 19/1/18
Location: Corporate Governance Shared Drive – GL380
5
Paediatric Guidelines – Neonatal sepsis & observation (GL380) January 2018

AFTERCARE
If there have been any concerns about early-onset neonatal infection before a baby is
discharged, advise the parents and carers verbally and in writing that they should seek
medical advice (for example, from NHS Direct, their general practice, or an accident and
emergency department) if they are concerned that the baby is showing any of the
following signs (this is contained in the standard obstetric discharge information)
 abnormal behaviour (for example, inconsolable crying or listlessness)
 unusually floppy
 has developed difficulties with feeding or with tolerating feeds
 has an abnormal temperature unexplained by environmental factors (lower than
36°C or higher than 38°C)
 has rapid breathing
 has a change in skin colour.

If a baby has been treated for suspected or confirmed early-onset neonatal infection:
 inform the parents and carers about potential long-term effects of the baby's illness
and likely patterns of recovery, and reassure them if no problems are anticipated
 take account of parents' and carers' concerns when providing information and
planning follow-up.

When a baby who has had a group B streptococcal infection is discharged from hospital:
 advise the woman that if she becomes pregnant again:
o there will be an increased risk of early-onset neonatal infection
o she should inform her maternity care team that a previous baby has had a
group B streptococcal infection
o antibiotics in labour will be recommended
 inform the woman's GP in writing that there is a risk of:
o recurrence of group B streptococcal infection in the baby, and
o group B streptococcal infection in babies in future pregnancies.

If the woman has had group B streptococcal colonisation in the pregnancy but without
infection in the baby, inform her that if she becomes pregnant again, this will not affect the
management of the birth in the next pregnancy.

INTRAPARTUM ANTIBIOTICS
Maternal antibiotics should be provided as per the RCOG Green Top Guideline (No.36)
and according to the Maternity unit guideline at the Royal Berkshire Hospital.

Any baby born to a mother who has received intrapartum antibiotics should have vital
signs and clinical condition monitored for at least 12 hours (at 0, 1 and 2 hours and then 2-
hourly for 10 hours) using the Baby Observation Chart. Any abnormal observations should
be acted upon. The baby should be treated using the red-flag/non-red flag indicators as
above.

Author: P de Halpert Date: Jan 2018

Job Title: Consultant Paediatrician Review Date: Jan 2020
Policy Lead: Urgent Care Group Director Version: 2.4 ratified 19/1/18
Location: Corporate Governance Shared Drive – GL380
6
 Paediatric Guidelines – Neonatal sepsis & observation (GL380) January 2018

Late onset sepsis

These are often infants who are on Buscot but consider altering treatment for infants
presenting after 48 -72 hours on the postnatal ward.
The main consideration should be the higher risk of meningitis in these infants which often
does not present with the classic symptoms seen in older children or adults. Also
antibiotic choice should reflect the potential causative organisms.

Management Late Onset Sepsis in Neonates

SYMPTOMS MANAGEMENT FIRST LINE ANTIBIOTICS
Respiratory  Paediatric Review Flucloxacillin and Cefotaxime
Distress (Grunting is  If sepsis suspected clinically Partial Screen
always abnormal at
this stage)  Low threshold for LP particularly if neurological
symptoms or signs
Increased
Ventilatory  Commence IV Antibiotics
requirements  If on postnatal ward admit to Buscot for observation
Increased CPAP
time

Unwell neonate,  Paediatric Review urgently Flucloxacillin and Cefotaxime

signs or symptoms  Partial Screen including CXR and urine
suggestive of
sepsis  LP when clinically stable
 Supportive care
 Commence IV Antibiotics

Signs or symptoms  Paediatric Review Cefotaxime, Flucloxacillin and

suggestive of NEC  Partial screen Metronidazole
or intra-abdominal (Cefotaxime and Flucloxacillin
sepsis  Abdominal X-ray
if umbilical flare only)
 NBM with ng tube
 Commence iv antibiotics

Signs or symptoms  Paediatric Review early Cefotaxime and Vancomycin

suggestive of  Examination of catheter insertion site When using Vancomycin,
sepsis with a check renal function prior to
percutaneously  Partial Screen including CXR and urine
commencement and ensure
inserted central  Consideration of LP if clinically stable that levels are taken (pre the
catheter ( Long-line)  Commence IV Antibiotics 3rd dose) and acted upon
or umbilical line in-
situ  Supportive care
 Consider line removal ( see below)

Deterioration or  Clinical Review Options – to be discussed with

failure to improve  Repeat blood cultures consultant
on first line - Ceftazidime
antibiotics  LP if not previously done
- Meropenem
 Consider viral/fungal infections
- Gentamicin
 Consider “Hidden infection” e.g. endocarditis or
osteomyelitis or line infection - Vancomycin

Author: P de Halpert Date: Jan 2018

Job Title: Consultant Paediatrician Review Date: Jan 2020
Policy Lead: Urgent Care Group Director Version: 2.4 ratified 19/1/18
Location: Corporate Governance Shared Drive – GL380
7
 Paediatric Guidelines – Neonatal sepsis & observation (GL380) January 2018

When to consider the removal of a Long-line

We are often faced with a preterm infant who is clinically septic with a long-line in situ.
This long-line may be providing vital nutrition or delivering important medication (e.g.
Inotropes) and vascular access may have proved extremely difficult previously. The table
below gives guidance as to how to manage this problem, most importantly ensure
alternative venous access is secured before removing any long line and discuss with
senior staff.
In some cases it may be appropriate to remove the long line before culture results are
known

Culture Result Management

Positive Blood Culture
Coagulase Negative
Staphylococci (CONS)
If clinically stable and the long-line cannot be removed
 Antibiotic treatment for minimum 7 days
 Re-culture at 5 days and if BC negative continue antibiotic treatment for 7
days in total
 Any suggestion of deterioration or failing to achieve negative cultures then
remove the long-line
If long-line removed
 Treat until negative cultures and for at least 48 hours after long line removal
 All cases should be re-cultured after completing course of antibiotics
 Consider monitoring CRP

Positive Blood culture Remove the long-line after the successful placement of peripheral line
Staphylococcus Aureus, Gram  Treat according to organism type
negative organisms or Fungus

Negative culture clinically Leave line in situ

stable
 Consider stopping antibiotics after cultures negative (at 36hrs) or treat as
suspected CONS sepsis
 Careful on going assessment if antibiotics stopped after only 48 hours
 Low threshold for restarting antibiotics

Negative culture not improving Remove the long-line after the successful placement of peripheral line
or clinical deterioration
 Treat with antibiotics for at least 48 hours after line removal
 Re-culture
 Consider broadening antibiotic therapy and antifungals if not improving

Author: P de Halpert Date: Jan 2018

Job Title: Consultant Paediatrician Review Date: Jan 2020
Policy Lead: Urgent Care Group Director Version: 2.4 ratified 19/1/18
Location: Corporate Governance Shared Drive – GL380
8
Paediatric Guidelines – Neonatal sepsis & observation (GL380) January 2018

Investigation of Invasive Fungal Disease in Neonates

Fungal infection should be considered if the following risk factors are present. Urine and
blood cultures should be sent however more extensive investigations and treatment
should not be commenced without prior discussion with the on call neonatal consultant.

Risk factors
 Late onset sepsis
 Infants < 1500g or < 25 weeks
 Unexplained thrombocytopenia
 Unexplained hyperglycaemia
 Infants receiving prolonged/multiple courses of antibiotics
 Infants with central line and TPN administration
 Use of ranitidine/omeprazole
 Post abdominal surgery
 Poor skin integrity
 Infants not improving on first line antibiotics
 Oral or perineal Candidal rash

Investigations
Candida can be difficult to detect and treatment may need to start based on clinical
suspicion before infection confirmed
 Prolonged blood culture (need to add comment on blood culture request)
 Repeat blood cultures (samples can be intermittently positive)
 CSF culture ( high risk of meningitis in systemic infection)
 SPA/catheter urine for hyphae and fungal culture
 CXR
 CSF

After discussion with senior medical staff the following can also be considered
 Ophthalmology assessment for chorioretinitis
 Liver and renal ultrasound
 Echocardiography

Treatment
 Liposomal Amphotericin B intravenously for 3 weeks (2 weeks post last positive
culture)
o Test dose required with monitoring of renal and liver function during usage
(see cBNF)
 Removal of central line once peripheral access obtained
NB Localised skin or oral infection can be treated with simultaneous administration of
topical and oral preparations in term well infants but investigation, monitoring and
treatment of invasive fungal disease should be considered for high risk infants.

Author: P de Halpert Date: Jan 2018

Job Title: Consultant Paediatrician Review Date: Jan 2020
Policy Lead: Urgent Care Group Director Version: 2.4 ratified 19/1/18
Location: Corporate Governance Shared Drive – GL380
9
 Paediatric Guidelines – Neonatal sepsis & observation (GL380) January 2018

Patient Details Baby Observation Chart

Date

Time
240
230
o
40 C 220
210
o
39 200
190
o
38 180
o
37.5 170
o
37 160
o
36.5 150
o
36 140
130
o
35 120
110
100
90
80
70
Resp 60
50
40
30
Intermittent
Grunting
Continuous
grunting
Mild Recession
Significant
recession
Colour:
pink/blue/pale
BM
Fed
Vomited
On heater
On
phototherapy
Signature

Observations should be recorded 2-4 hourly for 12-24 hours and daily if on IV antibiotics unless
Paediatrician advises additional checks
Values falling outside of the shaded areas should be discussed with the midwife in charge and
the Paediatrician informed. Please also notify the Paediatrician if any other concerns.
Date
Time
Reason for
observations
BMs required
Drug withdrawal
scoring required
SIGNED
Title

Author: P de Halpert Date: Jan 2018

Job Title: Consultant Paediatrician Review Date: Jan 2020
Policy Lead: Urgent Care Group Director Version: 2.4 ratified 19/1/18
Location: Corporate Governance Shared Drive – GL380
10
Paediatric Guidelines – Neonatal sepsis & observation (GL380) January 2018

Well infants
All infants require a set of observations at birth prior to transfer to the postnatal wards and
a second set at 4 hours of age.

If first observations are abnormal take corrective action (e.g. for low temperature)
consider Paediatric review and repeat observations 1-2 hours later with Paediatric review if
observations not improving.

At risk infants in the following groups require further observations at 1hr and 2hrs
of life and thereafter 2hrly for 12hours.

1. Sepsis Risk
2. Significant Meconium – (defined as dark green/black liquor that is thick and
tenacious or meconium stained liquor with visible lumps of meconium)
3. Group B Strep
i. If GBS positive swab in this pregnancy or invasive GBS in previous neonate
irrespective of whether mother has received intrapartum antibiotics
ii. If GBS swab positive in previous pregnancy (but not invasive disease in
previous baby) and not screened in this pregnancy irrespective of whether
mother has received intrapartum antibiotics

Other situations:
 If any abnormal observations in previous 12 hours: Continue 4 hrly for further 12
hours after clinical review
 Infants on iv antibiotics: once daily after first 24hours whilst still on iv therapy
 A baby born to a mother who was GBS swab +ve in a previous pregnancy (with no
invasive GBS in that baby), and swab negative in this pregnancy does not
additional observations.

Any concerns or abnormal observations should be discussed with the Paediatrician

Any infant requiring more than 2 reviews by the ST1-3/FY Neonatal doctor/ANNP for the
same problem should be discussed with the Neonatal Registrar.

Author: P de Halpert Date: Jan 2018

Job Title: Consultant Paediatrician Review Date: Jan 2020
Policy Lead: Urgent Care Group Director Version: 2.4 ratified 19/1/18
Location: Corporate Governance Shared Drive – GL380
11