Neonatal Sepsis
• Neonatal sepsis is defined as a clinical
syndrome of bacteremia with systemic signs
and symptoms of infection in the first 4 weeks
of life.
• Neonatal infection is a major cause of
mortality and morbidity in Ethiopia.
Classification
1. Early-onset neonatal sepsis (EONS) are
acquired before or during delivery. It occurs
from birth to 7 days, usually less than 72 hrs.
Pneumonia is common in EONS.
2. Late-onset neonatal sepsis (LONS) are
acquired after delivery in the normal newborn
nursery, neonatal intensive care unit (NICU),
or the community. It occurs after the first week
- 28 days. Meningitis is common in LONS.
Etiology
• Staphylococcus aureus
• Klebsiella and
• Escherichia coli were found to be the
commonest organisms causing bacterial
neonatal sepsis in Tikur Anbesa hospital.
Clinical features
• Signs and Symptoms of infection in newborn
infants could be non-specific or focal signs of
infection.
• Suspect bacterial infection if the infant has one
or more of the following danger signs:
– Abnormal vital signs
– Fever (temp >38 ºC), hypothermia (temp <36 ºC)
or temperature instability
– Tachycardia (HR > 180) or bradycardia (HR <80)
Cont…
– Tachypnea (RR > 60) or bradypnea (RR < 30) including
apnea
– Poor perfusion: capillary refill time > 3 seconds,
hypotension
– Abnormal breathing: gasping, grunting, severe chest
indrawing, nasal flaring or apnea
– Abnormal color: cyanotic, pale, grey, mottled,
jaundiced, erythematous including umbilical flare
– Abnormal activity: tremors, irritability, seizures,
floppiness, stiffness or minimal response to
stimulation, lethargy
Cont…
– Abnormal feeding: poor feeding, abdominal
distention, recurrent vomiting, diarrhea, otherwise
unexplained hypo- or hyperglycemia
– History of convulsions
– Severe Jaundice
– Bulging fontanelle
– If the infant has signs or risk factors for sepsis,
immediately notify the doctor, obtain blood for
laboratory testing and start IV antibiotics.
– Premature or low birth weight <2.0 kg
Maternal risk factors
• Maternal fever (temp >38ºC) during labor or within 24
hours after delivery
• Maternal urinary tract infection in current pregnancy or
bacteriura
• Duration of membrane rupture > 18 hours before delivery
• Uterine tenderness or foul smelling amniotic fluid
• Obstetric diagnosis of chorioamnionitis
• Meconium stained amniotic fluid
• Resuscitation at birth
• Invasive procedures
• Home delivery
Septic workup
• Consider blood culture and sensitivity whenever possible and
modify that treatment accordingly.
• CBC (Complete Blood Count with differential).
• Concern for sepsis if:
– Total WBC is abnormal (<5,000 or >20,000)
– Differential with granulocytes >70%.
• ESR or CRP. Concern for sepsis if positive.
• Consider urinalysis and gram stain if symptoms of urinary tract
infection or more general concerns for sepsis in infant >1 week old
• Consider lumbar puncture if concern for meningitis (lethargy,
irritability, convulsions, bulging fontanel, meningismus).
• Consider chest x-ray if respiratory distress or oxygen de-saturation.
Neonatal meningitis
• A diagnosis of meningitis should be made based on
clinical evidence (abnormal neurological exam:
seizures, abnormal tone and full fontanell) and CSF
analysis.
CSF analysis suggestive of meningitis:
• Identification of organism on gram stain or culture
• WBC count greater than or equal to 20 cells/mm3
• Low glucose (less than two third of serum value) and
• Protein greater than 150 mg/dl
Treatment
For early onset (less than 7 days)
• Antibiotic – Ampicillin and Gentamycin
• Duration: If positive cultures – minimum 10 days.
• If negative cultures, and clinically well, with normal CRP or
ESR– stop after 48 hours
• If negative cultures, but not clinically well, abnormal CXR or
elevated CRP – treat as confirmed sepsis.
• If no improvement after 48 hours, or worsens, after repeating
blood cultures ( if possible) and considering further
investigations, consider changing to: Ceftriaxone and
gentamicin
Cont…
For late onset (7-28 days)
• Antibiotic – Ampicillin and Gentamicin
• In certain cases if patient is critically sick or
staphylococcal infection is likely (pustular skin rash,
osteomylitis…) start with triple antibiotics
(cloxacilline, ampicillin and gentamycine)
• If no improvement after 48 hours, or the infant’s
condition worsens, consider changing antibiotics to:
Cloxacillin, ceftriaxone and gentamicin or
vancomycine and gentamicin
Treatment of neonatal sepsis with meningitis
• Antibiotics the same as for sepsis but with higher dose
and prolonged duration, for 21 days and Gentamycin
should be stopped on the 14th day.
Table 3: Antibiotic Dosing Chart for Newborns
Antibiotic Dosing Chart for Newborns
Medication Dose/Frequency Comments
< 14 days > 14 days
< 35 weeks PMA* > 35 weeks PMA*
(if PMA not known use (if PMA not known use
current weight current weight
< 2.0 kg) > 2.0 kg)
50 mg/kg/dose IV every
150 mg/kg/dose IV every 12 hours 6 hours
Ampicillin or
If meningitis ruled out: 50 mg/kg/dose IV every 12 Meningitis: 100 -
Cloxacillin
hours mg/kg/dose IV every
6hr.
> 1 month:
3 mg/kg IV once a day
7.5 mg/kg IV once a
Gentamicin and once in 48 hrs in very 4 mg/kg IV once a day Use newborn dose through first month.
day
preterm babies.
50 mg/kg IV every 12 50 mg/kg IV every 8 Preferred over Ceftriaxone due to improved
Cefotaxime1 50 mg/kg every 6 hours
hours hours safety profile
50 mg/kg IV every 12 hours for sepsis/meningitis: 50 mg/kg x1 IM for pus Contraindicated in setting of jaundice or
Ceftriaxone2 draining from eye within 48 hours of IV calcium
For IM injection, dilute to 350 mg/mL. Max dose ½ mL = 175 mg administration
7.5 mg/kg IV every 24 7.5 mg/kg IV every 12 7.5 mg/kg IV every 8 Anaerobic coverage including treatment of
Metronidazole
hours hours hours necrotizing enterocolitis
20 mg/kg IV every 12 hrs 20 mg/kg IV every 8 hours Treatment of herpes simplex infection:
Acyclovir 14 days if localized,
20mg/kg PO every 6 hours if IV acyclovir not available 21 days if disseminated
