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.