Basics
Description
Mechanism
- Life-threatening infection of the newborn, rarely occurring as late as 3 mo of age
- Overwhelmingly bacterial:
- Rarely viral or fungal infection
- Organisms usually present in the maternal perineal flora
- Occurs in 3 " �5 newborns per 1,000 live births
- Risk factors:
- Perinatal:
- History of recent fever (>37.5 � �C)
- UTI
- Chorioamnionitis
- Prolonged rupture of membranes (>18 hr)
- Foul lochia
- Uterine tenderness
- Intrapartum asphyxia
- Neonatal:
- Prematurity
- Fetal tachycardia (>180 beats/min)
- Male
- Twinning (especially 2nd twin)
- Developmental or congenital immune defects
- Administration of IM iron
- Galactosemia
- Congenital anomaly (urinary tract, asplenia, myelomeningocele, sinus tract)
- Omphalitis
Etiology
Sepsis
- Bacterial:
- Group B Streptococcus
- Escherichia coli
- Listeria monocytogenes
- Coagulase-negative Staphylococcus
- Treponema pallidum
- Viral:
- Herpes simplex is a common viral etiology.
- Enterovirus
- Adenovirus
- Fungi:
- Protozoa:
Meningitis
- Bacterial:
- Group B Streptococcus
- E. coli type K1
- L. monocytogenes
- Other streptococci
- Nontypeable Haemophilus influenzae
- Coagulase-positive and coagulase-negative Staphylococcus
- Less commonly: Klebsiella, Enterobacter
- Pseudomonas, T. pallidum, and Mycobacterium tuberculosis
- Citrobacter diversus (important cause of brain abscess)
- Additional pathogens: Mycoplasma hominis and Ureaplasma urealyticum
- Viral:
- Enteroviruses
- Herpes simplex virus (type 2 more commonly)
- Cytomegaloviruses
- Toxoplasma gondii
- Rubella
- HIV
- Fungi:
- Candida albicans and other fungi
Diagnosis
Signs and Symptoms
History
- Nonspecific history:
- "Not acting normal " �
- Feeding poorly
- Irritable or lethargic
- General:
- Toxic appearing
- Altered mental status: Irritable or lethargic
- Apnea or bradycardia
- Mottled, ashen, cyanotic, or cool skin
Physical Exam
- Vital signs:
- Hyperthermia/hypothermia
- Tachypnea
- Tachycardia
- Prolonged capillary refill time
- Abdominal distention
- Jaundice
- Bruising or prolonged bleeding
- Sepsis syndrome in the neonate:
- Septic shock
- Hypoglycemia
- Seizures
- Disseminated intravascular coagulation (DIC)
- If untreated, cardiovascular collapse and death
Essential Workup
- Sepsis evaluation followed by empiric antibiotics and support
- Determine a source for the infection.
- Identify metabolic abnormalities.
Diagnosis Tests & Interpretation
Lab
- Bedside glucose determination
- CBC:
- WBCs elevated or suppressed
- Shift to the left
- Thrombocytopenia
- C-reactive protein (CRP)
- Urinalysis
- Cultures as soon as the diagnosis is entertained:
- Blood, CSF, catheterized or suprapubic urine, stool
- Lumbar puncture:
- May need to delay if hemodynamically unstable
- Cell count, protein, glucose, culture, Gram stain
- Serum glucose needed to exclude hypoglycemia
- Arterial blood gas and oximetry
- Metabolic acidosis is common.
- Electrolytes and calcium:
- DIC panel:
- Coagulopathy is a late complication.
- Monitor PT, PTT and fibrinogen-split products
Imaging
CXR to rule out pneumonia � �
Differential Diagnosis
- Heart disease:
- Hypoplastic left heart syndrome
- Myocarditis
- Metabolic disorders:
- Hypoglycemia
- Adrenal insufficiency (congenital adrenal hyperplasia)
- Organic acidoses
- Urea cycle disorders
- Intussusception
- Child abuse
- CNS:
- Intracranial hemorrhage
- Perinatal asphyxia
- Neonatal jaundice
- Hematologic emergencies:
- Neonatal purpura fulminans
- Severe anemia
- Methemoglobinemia
- Malignancy (congenital leukemia)
Treatment
Pre-Hospital
Cautions
- Ventilatory support if obtunded, apneic, or respiratory distress
- IV access
- Continuous monitoring
Ed Treatment/Procedures
- Implement empiric treatment for neonatal sepsis if presentation at all consistent, particularly if any risk factors are present.
- Administer antibiotics:
- Ampicillin and gentamicin or cefotaxime
- Add vancomycin if the patients condition continues to deteriorate or any suggestion of Streptococcus pneumoniae.
- Cefotaxime may be substituted for gentamicin.
- Support for septic shock if present
Medication
- Ampicillin: 200 mg/kg/d q6h IV/IM for infant >2 kg birth weight and >2 wk old; 150 mg/kg/d q8h if <7 days old
- Cefotaxime: 150 mg/kg/d q6h IV/IM for infants >2 kg birth weight and >1 wk old; 150 mg/kg/d q8h IV/IM if 8 " �28 days old; 100 mg/kg/d IV/IM q12h if 0 " �7 days old
- Gentamicin: 2.5 mg/kg/dose q8h IV/IM if postconceptual age >37 wk and >7 days old; 2.5 mg/kg/dose q12h if <7 days old
- Vancomycin: 15 mg/kg/dose IV q8h if postconceptual age >37 wk and >7 days old; 15 mg/kg IV q12h if <7 days old
Follow-Up
Disposition
Admission Criteria
- All patients with suspected sepsis are admitted to the hospital for supportive care, IV antibiotic therapy, and close monitoring.
- All children <1 mo with a fever are generally admitted even in the absence of significant suspicion of sepsis. Older children are admitted based upon the clinical presentation.
Initial Stabilization
- Airway management indicated if obtundation, apnea, or respiratory distress
- IV access to administer fluids and pressors as needed
- Continuous monitoring
Additional Reading
- American Academy of Pediatrics. Red Book: 2012 Report of the Committee on Infectious Diseases. 29th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2012.
- Edwards � �MS. Postnatal bacterial infections. In: Martin � �RJ, Fanaroff � �AA, Walsh � �MC, eds. Neonatal-Perinatal Medicine. Diseases of the Fetus and Infant. 9th ed. St. Louis, MO: Mosby; 2011:793 " �829.
- Ferrieri � �P, Wallen � �LD. Neonatal bacterial sepsis. In: Taesch � �HW, Ballard � �RA, Gleason � �CA. Averys Diseases of the Newborn. 9th ed. Philadelphia, PA: Elsevier Saunders; 2012:538 " �550.
- Shapiro � �NI, Zimmer � �GD, Barkin � �AZ. Sepsis syndromes. In: Marx � �JA, Hockberger � �RS, Walls � �RM, eds. Rosen's Emergency Medicine: Concepts and Clinical Practice. 7th ed. St. Louis, MO: Mosby; 2010:1848 " �1858.
- Van de Hoogen � �A, Gerards � �LJ, Verboon-Maciolek � �MA, et al. Long-term trends in the epidemiology of neonatal sepsis and antibiotic susceptibility of causative agents. Neonatology. 2010;97(1):22 " �28.
- Young � �TE, Mangum � �B. Neofax 2011: A Manual of Drugs Used in Neonatal Care.24th ed. Montvale, NJ: Physicians 'Desk Reference; 2011:2 " �105.
Codes
ICD9
- 038.0 Streptococcal septicemia
- 038.42 Septicemia due to escherichia coli [E. coli]
- 771.81 Septicemia [sepsis] of newborn
- 771.2 Other congenital infections specific to the perinatal period
- 038.3 Septicemia due to anaerobes
- 054.5 Herpetic septicemia
- 771.4 Omphalitis of the newborn
- 771.7 Neonatal Candida infection
ICD10
- P36.0 Sepsis of newborn due to streptococcus, group B
- P36.4 Sepsis of newborn due to Escherichia coli
- P36.9 Bacterial sepsis of newborn, unspecified
- P37.2 Neonatal (disseminated) listeriosis
- P36.39 Sepsis of newborn due to other staphylococci
- P36.5 Sepsis of newborn due to anaerobes
- P36.8 Other bacterial sepsis of newborn
- P37.5 Neonatal candidiasis
- P38.9 Omphalitis without hemorrhage
SNOMED
- 276669000 Bacterial sepsis of newborn (disorder)
- 403842002 Neonatal streptococcal infection (disorder)
- 206379003 sepsis of newborn due to Escherichia coli (disorder)
- 359646002 Neonatal disseminated listeriosis (disorder)
- 403000003 Neonatal systemic candidosis (disorder)
- 42052009 Omphalitis of the newborn (disorder)
- 448784003 Sepsis due to herpes simplex (disorder)
- 449505005 Sepsis due to coagulase negative Staphylococcus (disorder)