Neonatal Sepsis: Risk Factors, Clinical Features, Diagnosis & Treatment

Neonatal sepsis is an important topic in Pediatrics for the NEET PG Exam because it is a serious and potentially life-threatening condition that requires early recognition and appropriate management. It is a significant cause of morbidity and mortality in the neonatal period, especially in premature or low-birth-weight infants.

In this blog we’ll cover the associated risk factors, clinical features, diagnosis and treatment of neonatal sepsis. Keep reading.

Definition

A clinical syndrome characterized by signs and symptoms suggestive of systemic neonatal infection with or without bacteremia.

• Classification
  • Early onset sepsis (EOS)
  • Late onset sepsis (LOS)

Early onset sepsis

• Onset usually within within 1^st 72 hrs. of life
• Organisms responsible are usually derived from maternal genital tract like Group B streptococci, E.Coli.

Risk factors

• Mother:
  • Foul smelling liquor 
  • Premature rupture of membranes (≥ 24 hours prior to delivery)
• Delivery: 
  • Difficult/ prolonged labour (1st and 2nd stage duration > 24 hours)
  • Multiple Per-Vaginal examination (single nonsterile / ≥ 3 sterile examinations)   
• Baby:
  • Low Birth Weight 
  • Prematurity 
  • Perinatal asphyxia

Late onset sepsis

• Organisms acquired from environment   
• Community acquired (baby staying at home)
  • Staphylococcus aureus 
  • E. coli 
• Hospital Acquired (baby in hospital)
  • Acinetobacter 
  • Klebsiella 

NOTE: Meningitis is commonly associated with LOS

Risk Factors:                                          

Nosocomial	Community acquired
Prematurity	Poor hygiene
NICU admission	Poor cord care
Invasive procedures	Bottle feeding
Mechanical ventilation	Lack of breastfeeding
Use of stock solutions	Pre lacteal feeds

Note

• Exclusive breastfeeding helps in prevention of neonatal sepsis.
• Most Effective/ Important Method to Prevent Neonatal Sepsis   
• Proper Hand Washing of Caregivers for At Least 2 Minutes (6 Steps)

NOTE

Most Common Organism Responsible for Neonatal Sepsis    

In India	→	Acinetobacter > klebsiella
In hospitals in India	→	Acinetobacter > klebsiella
In hospitals across the world	→	E. coli
Early onset sepsis (world)	→	Group B- streptococcus
Overall throughout the world	→	Group B- streptococcus

Clinical Features

• Poor feeding or alteration in established feeding behavior (earliest manifestation)
• Temperature disturbances (Hypothermia > fever)
• Metabolic → Hypoglycemia, metabolic acidosis
  CNS Shrill cry, irritability, seizures, abnormal posturing
  Respiratory Tachypnea, hypoxia, respiratory distress
  GI Abdominal distension, feed intolerance 
• Severe sepsis:
  • Septic shock 
  • Multiple organ dysfunction 
  • DIC: Bleeding
  • Sclerema: Generalized, non-pitting edema seen in neonates with severe sepsis/ severe hypothermia

Diagnosis

Definitive Test (gold standard) → Blood Culture
Screening Test → Sepsis Screen 
Sepsis Screen
Components → Any 2 out of 4 → +ve sepsis screen 

1. ANC (Absolute Neutrophil Count) → < 1800/mm³
   ANC cutoff
   For term neonates: Manroe’s charts
   For VLBW neonates: Mouzinho’s charts
2. I-T ratio → >0.2
3. Micro ESR → >15 mm
4. CRP → > 1 mg/dl

• Positive sepsis screen has:
  Sensitivity= 90-100%
  Specificity= 80%
  Positive predictive value=25%
  Negative predictive value=99-100%

Supportive Tests: 

• Blood glucose
• CXR 
• Lumbar puncture & CSF study (in all cases of LOS and cases of EOS with neurological features) 

Treatment:                                                  

• Supportive Care 
  • Shift to Nursery/ NICU
  • Start IV fluids
  • Maintain normal temperature (36.5- 37.5 degrees) 
  • Maintain euglycemia
  • Maintain normal oxygen saturation
• Specific Treatment
  • I.V. broad Spectrum Empirical antibiotics
  • Indications

EOS

• Foul smelling liquor
• ≥ 3 risk factors for EOS
• <3 risk factors +clinical features suggestive of neonatal sepsis and +ve sepsis screen
• Strong clinical suspicion of EOS

LOS

• +ve sepsis screen
• Strong clinical suspicion

 Which antibiotics?

• Inj. Ampicillin + inj. Gentamicin 
  +
  Inj. Cefotaxime (3^rd generation cephalosporin), if meningitis present or suspected 

Duration of antibiotic therapy

Sepsis screen	Blood culture	CSF S/O meningitis	Duration of Antibiotics
-	-	-	3 days
+	-	-	1 week (7-10 days)
±+/-	++/-	-+	2 weeks 3 weeks

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