DEFINITION

Is a clinical syndrome characterized by

• systemic signs of infection
• positive blood culture in the first 28 days of life

encompasses various infections of newborn as pneumonia,

septicaemia, meningitis, osteomyelitis ,UTI
Incidence - in India 38/1000 live birth
CLASSIFICATION OF NEONATAL SEPSIS

Early onset
Sign and symptoms appear within first 72 hours of birth
Source of pathogen -maternal genital tract/delivery area
Predominant manifestation . . respiratory distress due to congenital pneumonia
Risk factors -Obstetric risk PROM >18 hours
chorioamnionitis
multiple PV examinations >3 in 24 hours
Neonatal risk-VLBW <1.5 kg
Prematurity<35 weeks gestation
Male sex
 ETIOLOGY
• Gram negative organisms
- Klebsiella pneumoniae
- Escherichia coli
- Acinetobacter baumanni
- Pseudomonas
- Citrobacter
• Gram positive organisms
-Staphylococcus aureus
-Staphylococcus albus
 CLINICAL MANIFESTATION
• Early fubns letharav, slugishness, poor feedln1, poor cry, lrt ltablltty,
hypothermia, loss of /Inadequate welat,t pin
• A1splratoly Tachypnea ,apnea, retractions, 1runtina ,cyanosls
• cardiac Tachycardia ,shock In late sta1e
• GIT Vomittna, diarrhea , abdominal distensions , hepn)Sl)lena.-.-1111¥
• llenll Olfluria due to renal failure
• CNS Excessive irritability, full frontanel, seizure, starrtna look,
hypertonla/hypotonia, apneic spells
• lflllftltOlollcll Pallor, DIC ,icterus ,bleedln& spots
• Ml Sderema,lmpetiao,petechial spots, cellulltls
• Ill cairn•• Metabolic acidosis ,hypoalycaemla
 INVESTIGATIONS

DIRECT EVIDENCE
Blood culture Gold standard test for confirming
should be done before starting antibiotics
1-2 ml of blood for neonate
ratio of blood to culture media 1:10
observed for 48 hours before declaring -ve
Quick results within 12-24 hours by automated BACTEC
and BACTEC ALERT
 LUMBAR PUNCTURE
• Lumbar puncture Is done in all cases of sepsis to rule out menln1itls
• Interpretation is difficult due to high CSF cell count In neonates( upto
32/cub mm with 60% polymorphs) and Increased protein
• CSF should be cultured immediately to avoid loss of viability of
microorganisms
• Gram stain
• Cell type ,cell count
• Blochemlcals -protein,
• Cut off used > 30cefls, > 60% polymorph , glucose<SO% of blood llucose
pn,tein>lSOml/dl In term babies >180md/dl in preterm babies '
 INDIRECT METHOD
n1auWlli■
.....
• , _ . . . 1 vatt&ty of twsts which are helpful for SCNenlnl ol

• Tt81 llulmqtll count (TLC): A. total leucoeyte count~ scmo/al-.

• M 1bao1uta MUtraDhll count (A.NC) of 0.20 means that lmmlb,n
......-.areowr20pan:ent otttietota1~ T h l l ~
11,.... bane m.now pushes fM!n the immature cells Into ••••

..==.~~
--·cllon- with sepsis and a fall of >15 mm dllllftlllll
a(,,f 11 Jive INJleln (CRP): A. CRP value of >10ml/l ls talan •
CIP II r1••lJiinl
• • 116 poslltA In alher conditions 11111 parlwrrlll
••ulla1t ■-.S. .,ndrOIIIL A
 lve sep sis saee n helps to rul e ou t seps is ho weve r a pasllt JI
• A nept pa rameters may bl
scree n ma y no t be co nfirm ato ry as the scr ee n
sit ive due to ma ny oth er clin ica l co nditions like PIH, Perlnatll
po
e
asphyxia, shock, meconium aspiration syndrom
• positive •sepsis screen"
• 1. Leukopenia (TLC
• 2 Neutropenla (ANC <SCXXJ//mm3
• 3. Immature neutrophil to total neutrophil (1/
n ratio (> 0.2}
• 4 Miao ESR (> 15 mm 1st hour)
• CIP +w (>10ma/l)
CSF EXAMINATION AND VALUES OF CSF FOR
DIAGNOSING MENINGITIS
• Lumbar puncture (LP) must be performed in all neonates with late-onset
sepsis.
• In EOS, CSF examination may be deferred in a neonate with RDS without
any risk factors for sepsis. In all cases it must be done preferably before
starting antibiotics.
• • In a neonate with meningitis not showing clinical recovery after
institution of antibiotics, LP should be repeated after 48 hours.

• Ideally, the CSF WBC count & CSF sugar must be performed within 30
minutes of drawing the sample. It must be noted that CSF WBCs and
glucose rapidly fall with time, giving spurious results.
 MANAGEMENT
Supportive care of a septic neonate
• Maintain TABC
• 2. Ensure optimum oxygenation (maintain Sp02 91-95%)
• 3 Maintain normoglycemia
• 4 Grve lnj Vit K 1mg if required
• 5. Avoid enteral feed if hemodynamically compromised, give
maintenance IV fluids but start orogastric feeds as soon as
hemodynamically stable
6 Consider exchange transfusion if there is sclerema
 Septicemia or Pneumonia B wt< 2 kg

ROUTE DURATION
I ANTIBIOTICS EACH DOSE -FREQUE-NCV

0 14 days age >14 days agelnJ IV

Amp1c1l1tn•
8 hrly IV 7-10 days
• 50 mg kg/dose 12 hrly

12 hrly 8 hrly 7 10 days

kg dose

doe 24h y 24hry IV 7 10 days

 For babies B wt > 2 kg
Antibiotic Each dose Frequency Frequency Route : Duration

lnJ Amp,ctlhn* or S0mg/kg/dose 12 hrly 8 hrly IV 7-10 days

lnJ cloxac1llin# 50 mg/kg/dose 12 hrly 8 hrly IV 7-10 days

AND

lnJ Gentam cm 50 mg/kg/dose 24hrly 24hrly IV 7-10 days

 Septicemia llnd Line Drugs
• Bwt< 2kg
Eich dose Frequency , Frequency Route Duration
Antibiotic I
I

0-14 days aae >14 days aae

J P perac in+ 100 mg/kg/dose 12 hrly Shrly IV 7-10 days

Ta oba tum
15 mg/kg/ dose 24 hrty 24 hrty IV 7-10days
Meningitis (For confirmed meningitis)
•Bwt<2kg
Antibiotic Each dose Frequency Frequency Route Duration

O- 7 days qe >7 days qe

lnJ Cefotax1me• SO mg/kg/dose 12 hrly 8 hrly IV 3 weeks

In Amlkadn•• 1S mcfq/ dose 24 hrty 24 hrty ft/ !•II•

 . Meningitis - llnd Line
Antibiotic Each dose Frequency Frequency Route I Duration
i
t

0- 7 days age >7 days age

lnJ Meropenem 40 mg/kg/dose 8 hrly 8 hrly IV 3 weeks

lnJ Am1kacm 15 mg/kg/ dose 24 hrly 24 hrly IV 3 weeks

CHANGE OF ANTIBIOTICS
• Empirical upgradation can be considered if there is no clinical
improvement by 48 hours of institution of antibiotics or there are
signs of deterioration earlier than that.
• In such circumstances (presence of signs of deterioration) one must
look for alternate explanation {hypoglycemia, hypothermia, MAS,
TTNB, RDS, Perinatal asphyxia) for the clinical signs and augment
supportive care.
• 1f improvement does not occur in 48-72 hrs one may consider
changing to llnd line antibiotics. Current evidence does not support
the use of serial CRP as a guide for deciding whether or not
ant1b1otics should be upgraded empirically.
 CONDITIONS DO NOT REQUIRE
ANTIBIOTICS
• Meconium Stained Amniotic Fluid
• Meconium Aspiration Syndrome
• Respiratory Distress Syndrome
• Perinatal Asphyxia
• Asymptomatic neonates with presence of 1-2 risk factors for EOS
• Jaundice
• Prematurity
• Cyanotic heart disease
 WHEN TO STOP ANTIBIOTICS
• Culture negative sepsis: If the blood culture is reported sterile at 48
hours, the following guidelines must be adhered
• Asymptomatic neonate (at risk of EOS) with positive sepsis
screen/screen not performed initiated on antibiotics: stop antibiotics.
• Symptomatic neonate with positive sepsis screen becomes
completely asymptomatic: stop antibiotics by 5-7
Culture positive sepsis: Stop antibiotics after 10-14 days
Meningitis: Stop antibiotics after completion of 21 days.
Mdllrll
lrAtdtt
BEST PRACTICES TO PREVENT NEONATAL
INFECTIONS
• Safe delivery practices
• Maternal tetanus immunization
• Early diagnosis and prompt treatment of all maternal infections
• Early & Exclusive breastfeeding
• No pre-lacteal feeds
• Cord should be kept clean and dry
• Avoid overcrowding
• Maintain hygiene
 WHEN TO REFER
After Initial stablHzatlon, If the baby's condition worsens or no
Improvement Is noted after 48 hours of treatment, the babv caulll
be considered for referral to higher center.
WDn■ninl ls Defined IS Dewtlopment of the Followilll Featunll
• Ra zp:llatory failure requlrtna mechanical ventilation
• UnnlsponSlve shock
• PmlMnt or refractory convulsions
• Ols11mlrated lnbavascular ~latlon d ~ b y ~ from puldil•
11111, jldtrO lnlmtlnal hemoi, 11119 or pulmonary haerriorrhlll
• 1111, ,wqulrtna a:hanle transfusion but faclltty Is not Nllllble