Podcast #232 - 10 Key Reminders to Avoid Missing Neonatal Sepsis

Neonatal sepsis can be subtle, especially early on.  It can rapidly progress to multisystem organ failure, meningitis, and death.  Given the real dangers of neonatal sepsis, we will focus on 10 key points to remember when evaluating for this lurking terror.

We have discussed the evaluation of fevers in a young infant (90 days or younger) as an EB Medicine podcast special.  For this specific discussion, a great resource is from a recent BMJ article.

#1 - Sepsis is Divided by Onset

• Early onset sepsis (EOS) is seen within 72 hours of birth and considered to be bacterial transmission from the mother during the perinatal period.
• Late onset sepsis (LOS) is seen within the first 3 months of life and is considered to be from postnatal environmental exposure to pathogens.
• There is ahigher incidence of LOS in premature infants.
• Common pathogens (grouped by frequency) are listed in the table below.

#2 - Look at the Vital Signs

• Check for fever, hypothermia, and tachypnea are key vital sign changes that are common in sepsis.
• Tachycardia and hypoxemia are also concerning for sepsis.
• Any abnormalities of vital signs should be addressed.

#3 - Watch for Common Changes

• Lethargy and new poor feeding are common early signs of sepsis.
• Infants with changes in their mental status, tone, or perfusion are also concerning and seen with relative frequency.

#4 - Other Signs and Symptoms

• There are a variety of other signs and symptoms to assess that could be present with neonatal sepsis but can be seen with EOS or LOS.
• The list in the table (organized by organ system) below is extensive but also includes some of those mentioned above.

#5 - Blood Culture

• The most important single test is the blood culture.
• Modern, automated blood culture detection systems are 100% accurate as long as there are at least 1-2 viable bacterial colony forming units (CFUs) in the sample and a sufficient volume is drawn.
• Since up to 25% of infected infants can have low concentrations of bacteria with less than 4 CFUs/mL, it is recommended to get at least 1 mL of blood.
• Obtain the blood culture prior to starting antibiotics.

#6 - Urine Culture

• Not routinely obtained in a standard EOS evaluation.
• May be considered when evaluating for LOS.

#7 - Potential Tests to Perform

• A CBC with a normal WBC count does not rule out sepsis.
• A normal CRP at 8-24 hours after birth and another 24 hours later may rule out sepsis as it carries a negative predictive value of 99.7% (but not perfect).
• Chest x-rays can be performed to look for pneumonia but it is difficult to distinguish from respiratory distress syndrome or transient tachypnea of the newborn.

#8 - Lumbar Puncture

• A lumbar puncture is indicated in four situations:
  • Blood culture is positive.
  • Clinical course or laboratory data strongly suggests bacterial sepsis.
  • Infant does not improve with appropriate antimicrobial therapy.
  • When there are clinical signs of central nervous system involvement such as lethargy, irritability (inconsolable crying), fever, or seizure.
• Keep in mind these recommendations (like some others in this post) vary compared to Podcast #174 that covered the febrile young infant.

#9 - Antibiotic Choice

• For EOS administer ampicillin and gentamicin.
• For LOS administer vancomycin and gentamicin or cefotaxime.
• These regimens may vary based on local bacterial prevalence, antibiotic resistance patterns, and recommended guidelines.

#10 - Morbidity and Mortality

• Neonatal sepsis has a case fatality rate of 2% in term infants, 20% in premature infants, and 30% with concomitant meningitis.
• In patients with Group B Streptococcus, 7% of EOS cases had confirmed meningitis and in 27% of LOS cases.
• Neonatal sepsis is associated with multiple forms of developmental delays.
• ​It is a somber reminder of why it is so important to be ever vigilant so we can recognize neonatal sepsis early to provide appropriate treatment quickly and improve outcomes.

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