Diagnosis and Treatment of Neonatal Sepsis: Reconciling

the COFN & CDC Guidelines

Ri h d A.
Richard A Polin
P li M.D.
MD
Morgan Stanley Children’s Hospital
Columbia University
 Expert Panels on Neonatal Sepsis

CDC: Centers for Disease COFN: Committee on

Control and Prevention Fetus and Newborn
Guidance for the Clinician in
Rendering Pediatric Care

CLINICAL REPORT

Management of Neonates With Suspected or Proven

Morbidity and Mortality Weekly Report
www.cdc.gov/mmwr Early-Onset Bacterial Sepsis
Recommendations and Reports November 19, 2010 / Vol. 59 / No. RR-10

Prevention of Perinatal Group B

Streptococcal Disease
abstract
Revised Guidelines from CDC, 2010 With improved obstetrical management and evidence-based use of
intrapartum antimicrobial therapy, early-onset neonatal sepsis is be-
coming less frequent. However, early-onset sepsis remains one of the
most common causes of neonatal morbidity and mortality in the pre-
term population. The identification of neonates at risk for early-onset
Richard A. Polin, MD and the COMMITTEE ON FETUS AND
NEWBORN
KEY WORDS
early-onset sepsis, antimicrobial therapy, group B streptococcus,
meningitis, gastric aspirate, tracheal aspirate, chorioamnionitis,
sepsis screen, blood culture, lumbar puncture, urine culture,
body surface cultures, white blood count, acute phase reactants,
prevention strategies

sepsis is frequently based on a constellation of perinatal risk factors ABBREVIATIONS

CLINICAL REPORT
that are neither sensitive nor specific. Furthermore, diagnostic tests
CFU—colony-forming units
CRP—C-reactive protein
for neonatal sepsis have a poor positive predictive accuracy. As a result, CSF—cerebrospinal fluid

Management of Neonates With Suspec

clinicians often treat well-appearing infants for extended periods of time,
even when bacterial cultures are negative. The optimal treatment of
GBS—group B streptococci
I/T—immature to total neutrophil (ratio)

Ø  MMWR Recomm Rep. 2010; 59: Pediatrics. 2012;129(5): 1006-1015.

PMN—polymorphonuclear leukocyte

Ø Early-Onset
infants with suspected early-onset sepsis is broad-spectrum antimicro-

Bacterial Sepsis
bial agents (ampicillin and an aminoglycoside). Once a pathogen is iden-
PPROM—preterm premature rupture of membranes
This document is copyrighted and is property of the American

1-36.
tified, antimicrobial therapy should be narrowed (unless synergism is
needed). Recent data suggest an association between prolonged empir-
Continuing Education Examination available at http://w ww.cdc.gov/mmwr/cme/conted.html
ical treatment of preterm infants (≥5 days) with broad-spectrum anti-
department of health and human services biotics and higher risks of late onset sepsis, necrotizing enterocolitis,
Academy of Pediatrics and its Board of Directors. All authors
have filed conflict of interest statements with the American
Academy of Pediatrics. Any conflicts have been resolved through
a process approved by the Board of Directors. The American
Academy of Pediatrics has neither solicited nor accepted any

abstract
Centers for Disease Control and Prevention
and mortality. To reduce these risks, antimicrobial therapy should be commercial involvement in the development of the content of
Richard A. P
this publication.
discontinued at 48 hours in clinical situations in which the probability
of sepsis is low. The purpose of this clinical report is to provide a The guidance in this report does not indicate an exclusiveNEWBORN
course of treatment or serve as a standard of medical care.
practical and, when possible, evidence-based approach
With improved obstetrical management and Variations, to the manage- evidence-based usecircumstances,
taking into account individual of KEY
may be WORDS
ment of infants with suspected or proven early-onset sepsis. Pediatrics appropriate. early-onset se
intrapartum antimicrobial therapy, early-onset neonatal sepsis is be-
2012;129:1006–1015 meningitis, ga
coming less frequent. However, early-onset sepsis remains one of the sepsis screen
most common causes of neonatal morbidity and mortality in the pre- body surface
INTRODUCTION prevention str
term population. The identification of neonates at risk for early-onset
 Epidemiología
Clinical Spectrum of Early-onset Neonatal Sepsis
•  EGB el principal patógeno y E. Coli 2º en frecuencia.
There are ~3300 invasive early-onset sepsis cases and 390 deaths in the
•  Estimación anual de 3.300 casos, con una mortalidad del 10%.
United states each year (2005-2008 data).
data)
GBS is the leading pathogen and E coli is second
2/3 E coli isolates are resistant to ampicillin.

Rate* Case fatality ratio

Black preterm 5.14 24.4%
Non black ppreterm 2.17 21.5%
Black term 0.89 1.7%
Non black term 0.04 1.6%

*/1,000 live births

Weston et al Pediatr. Inf Dis. J. 30: 937, 2011

(Rules)   (Guideline)  
 Recién nacido asintomático ≥ 37 semanas
y factores de riesgo (≠ corioamnionitis)

CDC
PAI   Observación  
incompleta   (Evaluación  opcional)  

COFN
Observación  
Evaluación  limitada*  

PAI   CDC
incompleta   Evaluación  limitada  
+  
HBR  ≥  18  h    
COFN Observación  
*Cuando observación no es posible Evaluación  limitada*  
 Yes Limited evaluation¶ prophylaxis, if the infant is well-appearing a
t
ɨF
EFmOJUJPO
PG
BEFRVBUF
JOUSBQBSUVN
BOUJC
Either <37 weeks Yesor duration
Observation for ≥48 hours†† laxis
of membrane rupture and 0is days’clarified asYes≥4 hours
gestational age andof IVthe penicillin,
duration
≥18 hours? Yes Signs of neonatal sepsis? Full diagnostic evaluation*
Mother received intravenous Observation for ≥48 hours††§§ cefazolin
rupture before before delivery
delivery (AII).
wasAntibiotic
<18 hours, All otherthen ag th
therapy†
penicillin, ampicillin, tions
be observedare considered
No inadequate
for ≥48 hours, and nofor purpose
routine dia
* Fullordiagnostic
cefazolin for ≥4 hoursincludes a blood culture, a complete blood count
evaluation management.
is recommended (BIII). If the infant is well-
before delivery?
(CBC) including white blood cell differential and platelet counts, chest ra-
diograph (if respiratory abnormalities are present), and lumbar puncture (if
t
8FMMBQQFBSJOH
JOGBOUT
XIPTF
NPUIFS
IBE
BO

either
Maternal <37 weeks
chorioamnionitis? § Yes and 0 days’ Limitedgestational
evaluation¶ age o
patient is stableNoenough to tolerate procedure and sepsis is suspected). GBS prophylaxis
of membrane but received
rupture before no therapy
delivery
Antibiotic or inadequat
was
† ≥18
† Antibiotic therapy should be directed toward the most common causes of
Morbidity and Mortality Weekly Report
neonatal sepsis, including Yes ampicillin
intravenous Observationfor GBS andhours
for ≥48 coverage
††¶¶ for infantNoshould
antibiotics canundergo
be managed with observation
a limited evaluation an f
≥37 weeks and durationwww.cdc.gov/mmwr unless
other organisms
of membrane
(including Escherichia coli and other gram-negative patho- for ≥48the hoursinfant is <37 weeks and 0 days’ g
(BIII).
and shouldrupture
Recommendations and Reports November 19, 2010 / Vol. 59 / No. RR-10
gens) take into account local antibiotic resistance patterns.
GBS or membranesindicated were No
<18 hours?
§ Consultation with obstetric providers is important to determine the level of prophylaxis
The following keyrupturedRoutine ≥18
changes werehours
clinical †† befo
caremade fr
Prevention
clinical suspicion of Perinatal
for chorioamnionitis. Group B is diagnosed clini-
Chorioamnionitis which
for
guidelines: case
mother?** a limited evaluation and observa
No
t
hours is recommended (BIII).
cally and some of the signs are
Streptococcal Disease nonspecific.
¶ Limited evaluation includes blood culture (at birth) and CBC with differential ɨF
BMHPSJUIN
OPX
BQQMJFT
UP
BMM
OFXCPSOT
Yes
and platelets Revised
(at orbirthGuidelines
and/or at 6–12 Yes
fromhours CDC,of2010 life).
Limited evaluation¶
t

t
8FMMBQQFBSJOH
JOGBOUT
XJUI
B
HFTUBUJPOBM
BHF
PG
ɨF
EFmOJUJPO
PG
BEFRVBUF
JOUSBQBSUVN
BOUJ
Either <37 weeks duration
** See table 3 for indications for intrapartum GBS
of membrane rupture
prophylaxis.
Observation for ≥48 hours†† whose
laxis is mothers
clarified received
Yes≥4 hours
as adequate
of IV intrapartu
penicillin,
††§§
†† If signs of sepsis develop, a full diagnostic evaluation should be conducted Motherprophylaxis
received intravenous Observation for ≥48 hours
≥18 hours?
and antibiotic therapy initiated. cefazolin do not routinely require
before delivery (AII). All other ag diagnost
§§ If ≥37 weeks’ gestation, observation may occur at home after 24 hours if other penicillin,
(CIII). ampicillin,
discharge criteria have been met, access to medical care is readily available, tionsforare
or cefazolin considered inadequate for purpos
≥4 hours
* Full
anddiagnostic
a person who evaluation
is able to includes
complyafully bloodwith culture, a complete
instructions blood
for home count
observa- management.
before delivery?
tion will
(CBC) be present.
including whiteIfbloodany ofcell these conditions
differential andis not met, the
platelet infant
counts, should
chest ra- Monitoring Implementation
t
8FMMBQQFBSJOH
JOGBOUT
XIPTF
NPUIFS
IBE
BO
be observed
diograph in the hospital
(if respiratory for at leastare
abnormalities 48present),
hours and until
and discharge
lumbar criteria
puncture (if
are achieved.
patient is stable enough to tolerate procedure and sepsis is suspected). and GBS Impactprophylaxisof
No
but Guidelines
received no or inadequa
†¶¶Antibiotic
Some experts therapy recommend
should bea directed
CBC withtoward differential and platelets
the most common at causes
age 6–12 of
hours. sepsis, including intravenous ampicillin for GBS and coverage for antibiotics can be managed with observation
t
-PDBM
BOE
TUBUF
QVCMJD
IFBMUI
BHFODJFT
JO
DPO
neonatal Yes
other organisms (including Escherichia coli and other gram-negative patho- unless
≥37 weeks the infant
and duration
appropriate groupsisof<37 Observation
weeksforare
hospitals, ≥48 hours
and 0 ††¶¶
days’ g
encourage
gens) and should take into account local antibiotic resistance patterns. of membrane
or membranes
surveillancerupture for were ruptured
early-onset GBS ≥18disease
hoursand befo
§ Consultation with obstetric providers is important to determine the level of
<18 hours?
which
steps tocase
promotea limited evaluation
perinatal GBS disease and preven
observ
clinical suspicion for chorioamnionitis. Chorioamnionitis is diagnosed clini-
cally and some of the signs are nonspecific.
¶ Limited
hoursNoistorecommended
cation reduce the incidence (BIII). of early-onset
evaluation includes blood culture (at birth) and CBC with differential
Continuing Education Examination available at http://w ww.cdc.gov/mmwr/cme/conted.html

and platelets (at birth and/or at 6–12 hours of life). t
in

8FMMBQQFBSJOH
JOGBOUT
XJUI
B
HFTUBUJPOBM
BHF
P
their states (CIII).
** See table department
3 for indications for intrapartum
of health and human GBS prophylaxis.
services whose mothers Yes received adequate intrapart
†† If signs ofCenters
sepsis develop,
for Disease a fullControl
diagnostic and evaluation
Preventionshould be conducted Either <37 weeks or duration Limited evaluation¶
and antibiotic therapy initiated.
prophylaxis do not routinely Observationrequire diagnos
for ≥48 hours ††
of membrane rupture
§§ If ≥37 weeks’ gestation, observation may occur at home after 24 hours if other (CIII).
discharge criteria have been met, access to medical care is readily available, ≥18 hours?
and a person who is able to comply fully with instructions for home observa-
tion will be present. If any of these conditions is not met, the infant should Monitoring Implementation
 Rendering Pediatric Care

CLINICAL REPORT

Management of Neonates With Suspected or Proven

Early-Onset Bacterial Sepsis
 
abstract Richard A. Polin, MD and the COMMITTEE ON FETUS AND
NEWBORN
With improved obstetrical management and evidence-based use of KEY WORDS

Algoritmos  de  manejo  del  recién  nacido:  

intrapartum antimicrobial therapy, early-onset neonatal sepsis is be-
coming less frequent. However, early-onset sepsis remains one of the
most common causes of neonatal morbidity and mortality in the pre-
term population. The identification of neonates at risk for early-onset
early-onset sepsis, antimicrobial therapy, group B streptococcus,
meningitis, gastric aspirate, tracheal aspirate, chorioamnionitis,
sepsis screen, blood culture, lumbar puncture, urine culture,
body surface cultures, white blood count, acute phase reactants,
prevention strategies

1.  Evaluación  Recién  nacido  asintomáOco  con  factor  de  riesgo:  

sepsis is frequently based on a constellation of perinatal risk factors
that are neither sensitive nor specific. Furthermore, diagnostic tests
ABBREVIATIONS
CFU—colony-forming units

CorioamnioniOs  materna.  
CRP—C-reactive protein
for neonatal sepsis have a poor positive predictive accuracy. As a result, CSF—cerebrospinal fluid
clinicians often treat well-appearing infants for extended periods of time, GBS—group B streptococci
I/T—immature to total neutrophil (ratio)
even when bacterial cultures are negative. The optimal treatment of PMN—polymorphonuclear leukocyte
infants with suspected early-onset sepsis is broad-spectrum antimicro-
2.  Evaluación  Recién  nacido  asintomáOco  ≥  37  semanas  con  factor  
PPROM—preterm premature rupture of membranes
bial agents (ampicillin and an aminoglycoside). Once a pathogen is iden- This document is copyrighted and is property of the American
tified, antimicrobial therapy should be narrowed (unless synergism is Academy of Pediatrics and its Board of Directors. All authors

de  riesgo:  ≠  CorioamnioniOs  materna.  

needed). Recent data suggest an association between prolonged empir-
ical treatment of preterm infants (≥5 days) with broad-spectrum anti-
biotics and higher risks of late onset sepsis, necrotizing enterocolitis,
and mortality. To reduce these risks, antimicrobial therapy should be
have filed conflict of interest statements with the American
Academy of Pediatrics. Any conflicts have been resolved through
a process approved by the Board of Directors. The American
Academy of Pediatrics has neither solicited nor accepted any
commercial involvement in the development of the content of

3.  Evaluación  Recién  nacido  asintomáOco  ≤  37  semanas  con  factor  

this publication.
discontinued at 48 hours in clinical situations in which the probability
of sepsis is low. The purpose of this clinical report is to provide a The guidance in this report does not indicate an exclusive
course of treatment or serve as a standard of medical care.

de  riesgo:  ≠  CorioamnioniOs  materna.  

practical and, when possible, evidence-based approach to the manage-
ment of infants with suspected or proven early-onset sepsis. Pediatrics
Variations, taking into account individual circumstances, may be
appropriate.
2012;129:1006–1015

INTRODUCTION Pediatrics.  2012;129(5):  1006-­‐1015.  

“Suspected sepsis” is one of the most common diagnoses made in the
NICU.1 However, the signs of sepsis are nonspecific, and inflammatory
syndromes of noninfectious origin mimic those of neonatal sepsis. Most
infants with suspected sepsis recover with supportive care (with or
 Evaluación Recién nacido asintomático
Factor de riesgo: Corioamnionitis

  HemoculOvo  al  nacer    

ATB  amplio  
CorioamnioniOs*   Hemograma  ±  PCR  
espectro  
  6-­‐12  horas  de  vida  

Evaluación  

 
HemoculOvo   HemoculOvo  negaOvo   HemoculOvo  negaOvo  
posiOvo   EF  normal   EF  normal  
Laboratorio  anormal   Laboratorio  normal  
 

ConOnuar  ATB   ConOnuar  ATB     Suspender  ATB    

Punción  lumbar   48-­‐72  horas     48  horas  
si  la  madre  ATB    
durante  el  parto  
Interpre5ng  Complete  Blood  Counts  Soon  A:er  Birth  
In  Newborns  at  Risk  for  Sepsis  

Leucocitos Neutrófilos
Are Complete Blood Cell Counts Useful in the Evaluation of Asymptomatic
Neonates Exposed to Suspected Chorioamnionitis?
selected f
masked th
Gregory L. Jackson, William D. Engle, Dorothy M. Sendelbach, Debra A. Vedro, Sue
Josey, Jodi Vinson, Carol Bryant, Gary Hahn and Charles R. Rosenfeld
Pediatrics 2004;113;1173

The online version of this article, along with updated information and services, is
tational ag
as eviden
located on the World Wide Web at:
http://pediatrics.aappublications.org/content/113/5/1173.full.html

for infants
to 366⁄7 w
PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly
publication, it has been published continuously since 1948. PEDIATRICS is owned,
with a ges
Indice I/T Plaquetas
published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2004 by the American Academy

Third, al
of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

study, th
age at the
vals of te
Downloaded from pediatrics.aappublications.org at Hospital Virgen de la Salud Biblioteca on January 2, 2013

LR we r
smaller s
cases to
FIGURE 2
around th
ROC curves for WBC counts (A), ANCs (B), I/T ratio (C), and platelet counts (D) performed at !72 hours to stratify
Newman et al. Pediatrics 126: 903-90, 2010
according to age at the time of the CBC. unable to
cific comb
 Are Complete Blood Cell Counts Useful in the Evaluation of
Asymptomatic Neonates Exposed to Suspected Chorioamnionitis?

Gregory L. Jackson, MD, MBA*; William D. Engle, MD*; Dorothy M. Sendelbach, MD*; Are Complete Blood Cell Counts Useful in the Evaluation of Asymptomatic
Neonates Exposed to Suspected Chorioamnionitis?
Gregory L. Jackson, William D. Engle, Dorothy M. Sendelbach, Debra A. Vedro, Sue

bra A. Vedro, PNP‡; Sue Josey, PNP‡; Jodi Vinson, PNP‡; Carol Bryant, PNP‡; Gary Hahn, PNP‡; and Josey, Jodi Vinson, Carol Bryant, Gary Hahn and Charles R. Rosenfeld
Pediatrics 2004;113;1173

Charles R.ofRosenfeld,
Distribution Abnormal MD* Neutrophil Values in Infants Born The online version of this article, along with updated information and services, is
located on the World Wide Web at:

to Women with Chorioamnionitis http://pediatrics.aappublications.org/content/113/5/1173.full.html

STRACT. Objective. Chorioamnionitis complicates Eight required rehospitalization; none had evidence of
to 10% of pregnancies and increases the risk of neo- bacterial infection. If neutrophil values had been used to
l infection. Women with chorioamnionitis%receive determine duration of%antibiotics,
symptomatic then local costs
asymptomatic % would
asymptomatic
apartum antibiotics, often resulting in inconclusive have increased by $76 000 to $425 000 per year. (Schelonka)
PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly
publication, it has been published continuously since 1948. PEDIATRICS is owned,

(Manroe) published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2004 by the American Academy

natal blood cultures. Peripheral neutrophil values are Conclusions. Single or serial neutrophil values do not
of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

d frequently to assist in the diagnosis of neonatal

I/T-1 42%assist in the diagnosis of early-onset
20% infection or deter- 6%
ction and to determine duration of antibiotics; we mination of duration of antibiotic therapy in asymptom-
ght to determine the utilityI/T-2
of this approach. 47%atic, culture-negative neonates13% who are >35 weeks’ ges-
ethods. A prospective observational study was per- tation º   and are delivered of women with suspected Downloaded from pediatrics.aappublications.org at Hospital Virgen de la Salud Biblioteca on January 2, 2013

I/T-3 25% 5%
med in 856 near-term/term neonates who were ex- chorioamnionitis. Pediatrics 2004;113:1173–1180; intra-
ed to suspected chorioamnionitis. Each received anti- amniotic infection, neutrophil values, complete blood
ics for 48 hours unless clinical infection or positive count, early-onset infection, antibiotic therapy, length of
Jacksonwere
od cultures occurred. Peripheral neutrophils G L et stay,
al Pediatrics 113: 1173, 2004
resource utilization.
sured serially and analyzed using the reference
ges of Manroe et al; an additional analysis of only the
al neutrophil values used the normal ranges of Sche- ABBREVIATIONS. CDC, Centers for Disease Control and Preven-
ka et al. Results of neutrophil analyses were not used tion; CBC, complete blood cell count; ATN, absolute total neutro-
phil count; ATI, immature neutrophil count; I:T, immature neu-
etermine duration of therapy. Fifty percent of asymp- trophil count:absolute total neutrophil count proportion; NBN,
atic neonates were seen postdischarge to ascertain normal newborn nursery; GBS, group B streptococcus.
Recién nacido asintomático ≥ 37 semanas
Factor de riesgo ≠ Corioamnionitis
PAI  incompleta  
Observación  
o  
24-­‐48  horas  
BR  ≥  18  horas  

 Hemograma  ±  PCR   Evaluación  

6-­‐12  horas  de  vida  

Laboratorio  normal  
Laboratorio  anormal   EF  normal  
Alta  a  las  48  horas  

HemoculOvo  

HemoculOvo  negaOvo   Iniciar  ATB    

EF  normal   HemoculOvo  posiOvo  
Punción  lumbar  
Alta  a  las  48  horas  
 Use of the Complete Blood Cell Count
in Early-onset Neonatal Sepsis

Ø En un estudio con 166.092 neonatos con sospecha de sepsis

neonatal precoz.

Ø Cuando los valores de leucocitos, neutrófilos totales, índice I/T y

plaquetas fueron normales, solo 0,6% de los neonatos tenía un
hemocultivo positivo: VPN del 95%.

Ø Bajas cifras de leucocitos y neutrófilos totales, y altos índices de I/T

se asocia a un riesgo aumentado de hemocultivo positivo: VPP del
20-40%.

Hornik el al Pediatr. Inf. Dis; 31: 799-802. 2012

Recién nacido asintomático ≤ 37 semanas
Factor de riesgo ≠ Corioamnionitis
 
PAI  incompleta   HemoculOvo    
o   Hemograma  ±  PCR  
BR  ≥  18  horas   6-­‐12  horas  de  vida  
 

Evaluación  

Laboratorio  normal  
Laboratorio   EF  normal  
anormal   No  precisa  ATB  

ATB  amplio  espectro  

HemoculOvo  posiOvo  
HemoculOvo  negaOvo   Suspender  ATB    
ConOnuar  ATB  
EF  normal   después  48-­‐72  horas  
Punción  lumbar  
 Días de tratamiento antibiótico
Duration of Antibiotic Therapy
ü  Tratamiento antibiótico ≥ 5 días, durante los primeros días de vida, ha sido
asociado con incremento de mortalidad, NEC y sepsis neonatal tardía.
Prolonged therapy with antibiotics ( 5days) in the first few days of life
has been associated with increased mortality, NEC and late onset sepsis.
with

3.5
cs
ero Days on Antibiotic
mpared with Infants w

3.0
OR for NEC,

2.5

2.0

1.5

1.0

0.5
Com
Ze

0
1 to 2 3 to 4 5 to 6 7 to 8 9 to 10 >10

Days on Antibiotics

Cotten CM and the NICHD Network Pediatrics 123: 58-66, 2009, Kuppala
VS J Pediatr. 159: 720-25, 2011, Vanaja N J Pediatr. 159: 392-97, 2011
 Recomendaciones  
 

ü  En   pacientes   sintomáOcos   mantener   tratamiento   anObióOco  

durante  7  días.  

ü  En   ≥   35   semanas   y   asintomáOcos   no   mantener   tratamiento  

anObióOco  más  de  48  horas.  

ü  No   existen   datos   en   las   guías   clínicas   para   los   muy   prematuros,  
pero  recomienda  no  mantener  tratamiento  anObióOco  más  de  48-­‐72  
horas,   sí   los   culOvos   son   negaOvos   y   el   recién   nacido   se   encuentra  
asintomáOco.  
Definición de corioamnionitis
Definition of Chorioamnionitis

Elevated Histological Polymorphonuclear

cytokines or infiltration of
amniotic fluid placenta, membranes
Biochemical and umbilical cord

Microbiological

Maternal fever Clinical

tachycardia, Positive culture
leukocytosis, CRP, Positive PCR
vaginal discharge,
uterine tenderness.
Fetal tachycardia. Fetal
vasculitis
(funisitis)

Neonatal Sepsis
Corioamnionitis principal factor de riesgo
para sepsis neonatal precoz

•  RN  ≥  37  semanas  con  el  diagnosOco  de  sepsis  neonatal  precoz,  corioamnioniOs  fue  
Chorioamnionitis and the Risk of Neonatal Sepsis
documentada  en  el  35%  (histológicamente  el  90%).  
 
•  in Premature
CorioamnioniOs  inversamente   proporcional  a  Infants
la  prematuridad.  

22 wk 23 wk 24 wk 25 wk 26 wk 27 wk 28 wk
Histologic 70% 61% 59% 51% 48% 41% 34%
chorioamnionitis
Clinical 28% 26% 20% 19% 19% 15% 14%
chorioamnionitis
Early-onset sepsis 6% 4% 4% 2% 2% 2% 1%

Stoll et al Pediatrics 126: 443-456, 2010

 Es5ma5ng  the  Probability  of  Neonatal  Early-­‐Onset  
Infec5on  on  the  basis  of  Maternal  Risk  Factor    

}  Modelo  predicOvo  mulOvariable  (6  variables)  para  esOmar  la  

Are Complete Blood Cell Counts Useful in the Evaluation of Asymptomatic

probabilidad  para  desarrollar  sepsis  neonatal  precoz  en  

Neonates Exposed to Suspected Chorioamnionitis?
Gregory L. Jackson, William D. Engle, Dorothy M. Sendelbach, Debra A. Vedro, Sue
Josey, Jodi Vinson, Carol Bryant, Gary Hahn and Charles R. Rosenfeld
Pediatrics 2004;113;1173

neonatos  ≥  34  semanas.   The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pediatrics.aappublications.org/content/113/5/1173.full.html

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Puopolo et al. Pediatrics;128:1155-63. 2011

 Probability of Neonatal Early-Onset Infection Based on
Maternal Risk Factors for Infants > 34 weeks gestation

Gestational age (weeks/days)

Temperature
ROM (Hours)
GBS status (positive, negative, uncertain)
Maternal intrapartum treatment (GBS specific or broad spectrum)
Was IAP given 4 hours prior to delivery

Predicted probability(/1,000 live births) =

http://www.dor.kaiser.org/external/DORExternal/research/InfectionProbabilityCalculator.aspx
Puopolo et al 2011
 Probability of Neonatal Early-Onset Infection Based on
Maternal Risk Factors for Infants > 34 weeks gestation

Gestational age (weeks/days) 34 weeks 5 days

Temperature 99.5 F
ROM (Hours) 12.7 hours
GBS status (positive, negative, uncertain) Positive
Maternal intrapartum treatment GBS specific
Was IAP given 4 hours prior to delivery Yes

Predicted probability(/1,000 live births) = 0.8

http://www.dor.kaiser.org/external/DORExternal/research/InfectionProbabilityCalculator.aspx

Puopolo et al 2011
 Conclusiones

Ø Sepsis neonatal precoz causa importante de morbimortalidad

neonatal.

Ø Los algoritmos presentados por COFN son guías orientativas,

influye el “arte y la experiencia” del Neonatólogo.

Ø Los test de laboratorio son más útiles para excluir a los recién
nacidos sin infección, que para identificar a los infectados.

Ø Los antibióticos deben de suspenderse en 48-72 horas en aquellas

situaciones en las cuales la probabilidad de sepsis es baja.