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Iowa Neonatology Handbook: Infection
Suspected Sepsis in the Newborn
Jonathan M. Klein, MD
Peer Review Status: Internally Peer
Reviewed
- Due to various factors, newborn infants, both preterm
and full-term, are highly susceptible to sepsis during the newborn
period. In contrast to older infants, children and adults, the
signs of sepsis in the newborn are vague and nonspecific. The
earliest signs may be apnea, respiratory distress or poor feeding.
Other signs and symptoms include lethargy, temperature
instability, hyperbilirubinemia, bradycardia, seizures and
acidosis.
- When sepsis is suspected, a sepsis work-up
should be performed to include a CBC with differential, blood
culture and CSF for analysis and culture. Antibiotics should be
started as soon as the work-up is complete. Urine culture may be
omitted from sepsis work-ups done at birth but should be included
in subsequent sepsis work-ups. If there are other circumstances
indicating the origin of the sepsis, additional appropriate
cultures should be obtained, such as tracheal fluid or from an
area of cellulitis.
- Infants with sepsis frequently have an elevated absolute band
count, and/or depressed absolute neutrophil count, or increased
I:T ratio (See Total Granulocyte Count, p. 106, and reference
values for WBC indices, p. 107). However, a normal WBC
count in an infant with signs of sepsis (see I), does not rule out
infection, and thus antibiotics should be started while awaiting
culture results.
- The antibiotic regimen for sepsis work-ups performed at birth,
or admitted as a neonate less than 30 days old, is ampicillin and
gentamicin.
If the infant has been in the nurseries and sepsis is suspected,
the antibiotic regimen should include vancomycin and gentamicin.
Piperacillin should also be considered if there is suggestion of
possible gram-negative infection, e.g., in a tracheal aspirate
gram-stain, or if pseudomonas is present in the nursery.
Acyclovir therapy should be considered if HSV infection is
possible, pending the results of a work-up for HSV. This work-up
should include surface cultures for HSV, liver function tests and
CSF for cell count and HSV PCR.
- When a sepsis work-up has been performed, the infant should be
reassessed at 72 hours. Consideration can be given to
discontinuing antibiotics if the clinical course has not been
suggestive of infection and the cultures are negative.
If the blood cultures are positive, treat for 10 days. Obtain a
repeat blood culture after 24-48 hours of therapy to insure
effective therapy.
If the CSF culture is positive, treat for 14-21 days.
- In infants with positive cultures, antimicrobial therapy is
adjusted according to the sensitivities. Serum levels of
antibiotics should be followed as recommended on page XX.
- If C-reactive proteins (CRP) are obtained, an initial CRP of
<1 is not a definite confirmation of the absence of infection.
If obtained, serial levels 24 to 72 hours after the sepsis work-up
is performed should be obtained, and these values along with the
clinical course of the patient and the results of CBCs and
cultures will determine the duration of antibiotic therapy.
- Isolation requirements will be determined according to the
organism and the site of infection. Please consults the isolations
manual.
- If the patient is neutropenic, several therapies are possible:
- G-CSF at a dose of 10 µg/kg subQ or IV qday to b.i.d.
can be administered until the ANC is >1500.
- IVIG can be administered to augment the immune system until
the ANC has recovered.
- A granulocyte transfusion can be considered following
discussion with the staff neonatologist if definite or strongly
suspected infection is present. See Guidelines for Neonatal
Transfusion Therapy, p. 203.
- If the absolute neutrophil count is very low, a granulocyte
transfusion may be considered. This option should be discussed
with the staff neonatologist.
Reference:
Manroe BL, et al. The neonatal blood count in health and disease.
I. Reference values for neutrophilic cells. J Pediatr 1979;95:89-98.
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