Neonatal Sepsis is : A clinical syndrome of bacteraemia with systemic signs and symptoms of infection occurring in the first 4 weeks of life (neonatal period).
Overview of Neonatal Sepsis • Neonatal sepsis: A clinical syndrome of bacteraemia with systemic signs and symptoms
of infection occurring in the first 4 weeks of life (neonatal period)
• Also referred to as neonatal septicaemia
• When bacteria gain access into the blood stream, they may cause overwhelming infection
without much localization, (septicaemia) or may get predominantly localized to the lung
(pneumonia) or the meninges (meningitis)
• Neonatal sepsis is the single most important cause of neonatal deaths in Tanzania,
accounting for over half of them .
Classification and Causes • Early onset septicaemia
o Onset within 7 days of birth, almost all cases occur before 72 hours of life
o Group B streptococcus (GBS) and gram-negative enteric organisms (predominantly
Escherichia coli) account for most cases
o Other gram-negative enteric bacilli (e.g. Klebsiella sp) and gram-positive organisms Listeria monocytogenes, enterococci (e.g. Enterococcus faecalis) and Staphylococcus
aureus account for most other cases
o The organisms are prevalent in the maternal genital tract or in the delivery area
o Associated risk factors include preterm delivery, low birth weight (LBW), prolonged
rupture of membranes occurring ≥ 18 hours before birth, foul smelling amniotic fluid,
multiple vaginal examinations, maternal fever, difficult or prolonged labour and
aspiration of meconium
o Frequently manifests as pneumonia and less commonly as septicaemia or meningitis
• Late-onset septicaemia
o Caused by the organisms acquired from the environment
o Often transmitted through the hands of the care-providers
o Onset after 7 days of birth
o Presentation is that of septicaemia, pneumonia or meningitis
o Associated risk factors
LBW
Lack of breastfeeding
Superficial infections (umbilical sepsis)
Aspiration of feeds
Disruption of skin integrity with needle pricks and use of IV fluids
These factors enhance the chances of entry of organisms into the blood stream of
the neonates whose immunity is still poor.
Clinical Presentation of Neonatal Sepsis • Early signs are frequently nonspecific and subtle and do not distinguish among organisms
(including viral)
• Common early signs
o Diminished spontaneous activity, lethargy or floppiness
o Poor sucking (or inability to suck)
o Apnoea
o Bradycardia
o Temperature instability (hypothermia > fever)
o Tachypnea
o Respiratory distress (severe cases may become cyanosed)
o Vomiting
o Diarrhoea
o Abdominal distention
o Jitteriness
o Seizures or convulsions
o Jaundice
• Specific signs of an infected organ may pinpoint the primary site or site of dissemination
o Most neonates with early-onset GBS (and mainly with L. monocytogenes) infection
present with respiratory distress that is difficult to distinguish from Respiratory
Distress Syndrome (RDS)
o Periumbilical redness, discharge or bleeding may suggest omphalitis
o Coma, seizures, opisthotonus or a bulging anterior fontanelle suggests meningitis,
encephalitis or brain abscess
o Decreased spontaneous movement of a limb and swelling, warmth, redness or
tenderness over a bone or a joint indicated osteomyelitis or pyogenic arthritis
o Unexplained abdominal distension may indicate peritonitis or necrotizing enterocolitis
(particularly when accompanied by bloody diarrhoea).
Investigations • FBP, differential, and smear
o The normal WBC count in neonates varies, but values < 4,000/μL or > 25,000/μL are
abnormal
• The erythrocyte sedimentation rate (ESR) is often elevated.
Treatment • Antibiotic therapy
o Broad spectrum antibiotics
Ampicillin 50 mg/kg per dose (Q 8 to 12 hours for 0 to 7 days of age and Q 6 to 8
hours for 8 to 28 days of age) plus either gentamicin 2.5-5mg/kg per dose Q12
hours or cefotaxime 50 mg/kg dose (Q12 hrs for 0 to 7 days of age and Q8 hrs for
8 to 28 days of age)
Give first dose and refer urgently to hospital
• General supportive measures, including
o Provision of warmth
o Respiratory and hemodynamic management
References • Beattie, J., & Carachi, R. (2005). Practical Paediatric Problems (International student
Edition) London: Hodder Arnold.
• Behrman, R.E., & Kliegman, R.M. (2002). Nelson Essentials of Paediatrics. (4th ed.)
Pennsylvania: Saunders Company.
• Coovadia, H.M., et al. (2001). Paediatrics and Child Health: A Manual for Health
Professionals in the Third World. (4th ed.). Cape Town, South Africa: Oxford University
Press.
• MOHSW, WHO & UNICEF (2000). IMCI: Management of the Child with a Serious
Infection or Severe Malnutrition, Guidelines for Care at the First-referral Level. Dar es
Salaam, Tanzania: Ministry of Health and Social Welfare.
• Stanfield, P., & Bwibo, N. (2005). Child Health: A Manual for Medical and Health
Workers in Health Centres and Rural Hospitals. (3rd ed.) Nairobi: AMREF.
• Swai, M., et al. (2009). KCMC Paediatric Management Schedule. (7th ed.) Moshi,
Tanzania: Kilimanjaro Christian Medical Centre.