Presentation on Prevention and Management of Infants With Suspected or Proven Neonatal Sepsis References: American Academy of Pediatrics. Prevention and Management of Infants With Suspected or Proven Neonatal Sepsis, 2013. American Academy of Pediatrics. Management of Neonates With Suspected or Proven Early-Onset Bacterial Sepsis, 2012.

1. Prevention and Management of
Infants With Suspected or Proven
Neonatal Sepsis
Cristal Ann Laquindanum, MD-MBA
The Medical City
Pediatrics
NICU 2nd year resident

2. Reference:
 American Academy of Pediatrics. Prevention and
Management of Infants With Suspected or Proven
Neonatal Sepsis, 2013.
 American Academy of Pediatrics. Management of
Neonates With Suspected or Proven Early-Onset Bacterial
Sepsis, 2012.

3. Early-onset sepsis
 early-onset sepsis remains one of the most
common causes of neonatal morbidity and
mortality in the pre- term population.
 Identification of neonates at risk  based on a
constellation of perinatal risk factors that are
neither sensitive nor specific.
 diagnostic tests for neonatal sepsis  poor
positive predictive accuracy
 clinicians often treat well-appearing infants for
extended periods of time, even when bacterial
cultures are negative

4. Risk factors for early-onset neonatal sepsis
Major risk factors:
 preterm birth
 most closely associated
with early-onset sepsis
 maternal colonization with
GBS
 rupture of membranes >18
hours
 maternal signs or symptoms
of intra-amniotic infection
Other variables:
 ethnicity (ie, black
women are at higher risk
of being colonized with
GBS)
 low socioeconomic
status
 male sex
 low Apgar scores

5. Secondary prevention of GBS disease
Algorithm for the prevention of early-onset GBS infection in the newborn

6. Secondary prevention of GBS disease
Algorithm for the prevention of early-onset GBS infection in the newborn

7. SIGNS OF NEONATAL SEPSIS?
 Full diagnostic evaluation
 blood culture
 CBC count, including white blood
cell differential and platelet counts
 chest radiograph (if respiratory
abnormalities are present)
 lumbar puncture (if the patient is
stable enough to tolerate
procedure and sepsis is
suspected)
Signs of neonatal sepsis?

8. SIGNS OF NEONATAL SEPSIS?
 Antibiotic therapy
 most common causes of neonatal
sepsis, including intravenous
ampicillin for GBS and coverage
for other organisms (including
Escherichia coli and other gram-
negative pathogens) and should
take into account local antibiotic-
resistance patterns
Signs of neonatal sepsis?

9. Antibiotic Therapy
 Optimal treatment of infants with suspected early-onset
sepsis is broad-spectrum antimicrobial agents (ampicillin
and an aminoglycoside)
 Third-generation cephalosporin (eg, cefotaxime) represent
a reasonable alternative to an aminoglycoside
 BUT extensive/prolonged use of third-generation
cephalosporins is a risk factor for invasive candidiasis
 Ceftriaxone is contraindicated in neonates because it is
highly protein bound and may displace bilirubin, leading to
a risk of kernicterus.

10. Antibiotic Therapy
Healthy-appearing infants without
evidence of bacterial infection should
receive broad-spectrum antimicrobial
agents for no more than 48 hours
Small preterm infants, some may continue
antibiotics for up to 72 hours while
awaiting bacterial culture results.

11. Antibiotic Therapy
 Bacteremia without an identifiable focus of
infection is generally treated for 10 days
 Uncomplicated meningitis attributable to GBS is
treated for a minimum of 14 days
 Gram-negative meningitis is treated for
minimum of 21 days or 14 days after obtaining
a negative culture, whichever is longer.

12. Antibiotic Therapy
 Recent data suggest an association between
prolonged empirical treatment of preterm
infants (>5 days) with broad-spectrum
antibiotics and higher risks of late onset sepsis,
necrotizing enterocolitis, and mortality.
 To reduce these risks, antimicrobial therapy
should be discontinued at 48 hours in clinical
situations in which the probability of sepsis is
low.

13. Secondary prevention of GBS disease
Algorithm for the prevention of early-onset GBS infection in the newborn

14. MATERNAL CHORIOAMNIOTIS?
Signs of neonatal sepsis?
Maternal Chorioamnionitis?
 Definition:
 Maternal fever of > 38°C (100.4°F) and
at least two of the ff criteria:
 maternal leukocytosis
(> 15,000 cells/mm3)
 maternal tachycardia
(> 100 beats/minute)
 fetal tachycardia
(> 160 beats/minute)
 uterine tenderness, and/or
 foul odor of the amniotic fluid

15. Risk factors for chorioamniotis
 low parity
 spontaneous labor
 longer length of labor and membrane rupture
 multiple digital vaginal examinations (especially
with ruptured membranes)
 meconium-stained amniotic fluid
 internal fetal or uterine monitoring
 presence of genital tract microorganisms (eg,
Mycoplasma hominis)

16.  Limited evaluation
 blood culture (at birth) AND
 CBC count with differential and
platelets (at birth and/or at 6–12
hours after birth)
 Antibiotic therapy
Signs of neonatal sepsis?
Maternal Chorioamnionitis?
MATERNAL CHORIOAMNIOTIS?

17. MATERNAL CHORIOAMNIOTIS?
 Definition:
 Maternal fever of > 38°C (100.4°F) and
at least two of the ff criteria:
 maternal leukocytosis
(> 15,000 cells/mm3)
 maternal tachycardia
(> 100 beats/minute)
 fetal tachycardia
(> 160 beats/minute)
 uterine tenderness, and/or
 foul odor of the amniotic fluid
Signs of neonatal sepsis?
Maternal Chorioamnionitis?

18. Secondary prevention of GBS disease
Algorithm for the prevention of early-onset GBS infection in the newborn

19. Is GBS prophylaxis indicated?
 Indicated if 1 or more of the following is true:
(1) Mother is GBS-positive late in gestation and is not
undergoing cesarean delivery before labor onset
with intact amniotic membranes
(2) GBS status is unknown and there are 1 or more
intrapartum risk factors:
a. 37 weeks’ gestation
b. rupture of membranes for > 18 hours
c. or temperature of > 100.4°F (38.0°C)
(3) GBS bacteriuria during current pregnancy; or
(4) History of a previous infant with GBS disease.

20. Secondary prevention of GBS disease
Algorithm for the prevention of early-onset GBS infection in the newborn

21. Is GBS prophylaxis indicated?
 Routine clinical care
 Watch out for signs of sepsis
Signs of neonatal sepsis?
Maternal Chorioamnionitis?
GBS prophylaxis indicated?

22. Secondary prevention of GBS disease
Algorithm for the prevention of early-onset GBS infection in the newborn

23. Did mother receive at least 4 hours intrapartum
penicillin, ampicillin, or cefazolin?
 If > 37 weeks’ gestation
 Observation at home after 24 hours
 if other discharge criteria have been
met
 there is ready access to medical care
 a person who is able to comply fully
with instructions for home observation
will be present
 If any of these conditions is not met
 observed in the hospital for at least 48
hours and until discharge criteria have
been achieved.
Signs of neonatal sepsis?
Maternal Chorioamnionitis?
GBS prophylaxis indicated?
4 hrs intrapartum antibiotics?

24. Did mother receive at least 4 hours intrapartum
penicillin, ampicillin, or cefazolin?
 If signs of sepsis develop
 Full diagnostic evaluation
 blood culture
 CBC count, including white blood
cell differential and platelet counts
 chest radiograph (if respiratory
abnormalities are present)
 lumbar puncture (if the patient is
stable enough to tolerate
procedure and sepsis is suspected)
 Antibiotic therapy
Signs of neonatal sepsis?
Maternal Chorioamnionitis?
GBS prophylaxis indicated?
4 hrs intrapartum antibiotics?

25. Secondary prevention of GBS disease
Algorithm for the prevention of early-onset GBS infection in the newborn

26. > 37 weeks AOG AND
duration of membrane rupture <18 h?
Observe for > 48 hours
 If signs of sepsis develop
 Full diagnostic evaluation
 blood culture
 CBC count, including white blood
cell differential and platelet counts
 chest radiograph (if respiratory
abnormalities are present)
 lumbar puncture (if the patient is
stable enough to tolerate procedure
and sepsis is suspected)
 Antibiotic therapy
Signs of neonatal sepsis?
Maternal Chorioamnionitis?
GBS prophylaxis indicated?
4 hrs intrapartum antibiotics?
>37wks AND
membrane rupture <18h?

27. > 37 weeks AOG AND
duration of membrane rupture <18 h?
 Observe for 48 hours
 Some experts recommend a CBC
count with differential and platelets
at 6 to 12 hours of age.
Signs of neonatal sepsis?
Maternal Chorioamnionitis?
GBS prophylaxis indicated?
4 hrs intrapartum antibiotics?
>37wks AND
membrane rupture <18h?

28. Secondary prevention of GBS disease
Algorithm for the prevention of early-onset GBS infection in the newborn

29. < 37 weeks AOG OR
duration of membrane rupture >18 h?
 Observe for 48 hours
 Limited evaluation
 blood culture (at birth) AND
 CBC count with differential and platelets
(at birth and/or at 6–12 hours after birth)
 COFN: no blood culture unless
antibiotics are started because of
abnormal laboratory data
 Antibiotic therapy
Signs of neonatal sepsis?
Maternal Chorioamnionitis?
GBS prophylaxis indicated?
4 hrs intrapartum antibiotics?
>37wks AND
membrane rupture <18h?
<37wks AND
membrane rupture >18h?

30. < 37 weeks AOG OR
duration of membrane rupture >18 h?
 If signs of sepsis develop
 Full diagnostic evaluation
 blood culture
 CBC count, including white blood cell
differential and platelet counts
 chest radiograph (if respiratory
abnormalities are present)
 lumbar puncture (if the patient is
stable enough to tolerate procedure
and sepsis is suspected)
 Antibiotic therapy
Signs of neonatal sepsis?
Maternal Chorioamnionitis?
GBS prophylaxis indicated?
4 hrs intrapartum antibiotics?
>37wks AND
membrane rupture <18h?
<37wks AND
membrane rupture >18h?

31. Secondary prevention of GBS disease
Algorithm for the prevention of early-onset GBS infection in the newborn

32. Prevention and Management of
Infants With Suspected or Proven
Neonatal Sepsis
Cristal Ann Laquindanum, MD-MBA
The Medical City
Pediatrics
NICU 2nd year resident