Pediatric emergency medicine trisk 645

Suspect neonatal sepsis in any newborn presenting with hypothermia,
respiratory distress, hypoperfusion, or feeding difficulty.
Any neonate presenting with a concern for infection should be
hospitalized until cultures are proven negative.
Apnea is a common presentation of viral upper respiratory tract
infections (including respiratory syncytial virus infection) in a neonate.
Enteroviral infections are more severe in the neonate than children,
resulting in meningitis, acute fulminant hepatitis, and heart failure from
myocarditis.
RELATED CHAPTERS
Signs and Symptoms
Apnea: Chapter 14
Cyanosis: Chapter 21
Fever: Chapter 31
Septic-Appearing Infant: Chapter 73
Tachycardia: Chapter 77
Medical, Surgical, and Trauma Emergencies
Dermatologic Urgencies and Emergencies: Chapter 88
Infectious Disease Emergencies: Chapter 94
The Children’s Hospital of Philadelphia Clinical Pathway
ED Clinical Pathway for Evaluation/Treatment of Febrile Young
Infants (0–56 Days Old)
URL: />Authors: R. Scarfone, MD; P. Gala, MD; A. Murray, MD; M.K. Funari,
RN; J. Lavelle, MD; L. Bell, MD; C. Jacobstein, MD
Posted: August 2010, last revised August 2019

Neonatal Sepsis
CLINICAL PEARLS AND PITFALLS


Neonatal sepsis should always be considered in any sick newborn

presenting with symptoms of respiratory distress, hypotension,
electrolyte disturbance, poor feeding, or lethargy.
Neonatal sepsis often presents with hypothermia. Neonates may not
react to an infection with fever.
Avoid ceftriaxone due to its ability to displace bilirubin and aggravate
hyperbilirubinemia.
Neonates with a suspected UTI should have a full sepsis workup and
be admitted for intravenous antibiotic therapy.
Direct hyperbilirubinemia or new onset of jaundice after 8 days of life is
suspicious for a neonatal UTI.
Current Evidence
Concern for neonatal sepsis is one of the most commonly encountered clinical
situations for newborns in the ED. General incidence of sepsis in neonates is
approximately 0.98 per 1,000 live births. It can be categorized into early onset
(occurring in newborns who are less than 72 hours of life) or late onset (occurring
between 3 and 7 days of life).
Early-onset disease occurs through perinatal or vertical transmission from the
mother. Early-onset disease is caused by microbial flora present in the vaginal
tract (GBS, E. coli or other gram-negative bacilli, Staphylococcus aureus,
Enterococci, viridans group Streptococci, Group A Streptococci, syphilis, H.
influenzae , Listeria monocytogenes ). Risk factors for early-onset disease usually
relate to perinatal exposures (prolonged rupture of membranes, chorioamnionitis,
GBS-colonized mother with inadequate intrapartum antibiotics).
Late-onset disease may occur through horizontal transmission from the infant’s
environment or caregivers and is caused by environmental flora (Staphylococci,
E. coli, GBS, and candidiasis). Although more commonly seen in the NICU, risk
factors for late-onset disease include prematurity, presence of congenital heart
disease, gut pathology, and presence of central catheters.
Other pathogens causing sepsis include viral (herpes simplex, enterovirus,
cytomegalovirus, adenoviruses), fungal (systemic candidiasis), and atypical

bacteria (Toxoplasma) agents. Neonatal infection induces a systemic
inflammatory response which accounts for much of the capillary leak and
inflammation associated with the disease.


Clinical Considerations
Clinical Recognition. Neonatal sepsis presents within the first 4 weeks of life
with symptoms ranging from simply poor feeding to frank respiratory distress
and cardiovascular collapse ( Table 96.7 ). Hypothermia from inability to
maintain body temperature often occurs in babies with sepsis. Symptoms and
signs can be very nonspecific and sepsis should be considered as a differential
diagnosis in any symptomatic newborn. Neonatal sepsis can mimic any disease of
the newborn, including cardiac (cardiogenic shock from closure of a patent
ductus in ductal-dependent lesions), respiratory, endocrine, and metabolic
conditions. Viral and systemic fungal infections can have the same signs and
symptoms as bacterial sepsis.


TABLE 96.7
SIGNS AND SYMPTOMS OF NEONATAL SEPSIS