Pediatric emergency medicine trisk 2583 2583

granulocyte colony–stimulating factor but are not commonly used clinically.
CBC, CRP, and other nonspecific markers are useful indicators of disease. None
of these tests alone or in combination are sensitive enough to be used solely to
exclude the diagnosis of bacterial infection.
Definitive diagnosis is isolation of a specific pathogen from a normally sterile
site, such as blood, urine, or CSF culture. Blood samples for culture should be at
least 1 mL to allow for identification of low levels of bacteremia. A catheterized
urine specimen or suprapubic aspiration for urinalysis and urine culture is
recommended for all infants since ascending infection can lead to bacteremia.
CSF will show elevation in WBC count (20 to 30 cells/μL definitive), high
protein, and/or low glucose in bacterial infections. HSV encephalitis may
demonstrate elevated CSF protein only. CSF Gram stain may show presence of
bacteria. Lumbar puncture prior to antibiotic administration is recommended for
all neonates due to high incidence of meningitis (23%) in cases of bacteremia and
up to 30% of neonates may have a negative blood culture even in the presence of
bacterial meningitis. Lumbar puncture can be deferred if the infant has
hemodynamic instability but should be performed as soon as the infant is stable.
Infants should be placed on cardiorespiratory monitors during the lumbar
puncture procedure. Traumatic results should be interpreted with care. Correction
of CSF WBC count according to the RBC count in traumatic taps does not
improve the ability to diagnose meningitis. Clinicians should avoid this
correction and presume meningitis until the CSF culture results are available.
Other specific testing can be done (e.g., HSV CSF PCR, liver function tests, and
CSF enteroviral PCR) if specific pathogens are suspected. CXR can be helpful if
the neonate has respiratory or cardiac symptoms but is not routine.
Management. Any neonate with concern for bacterial or serious viral infection
should be admitted to the hospital. Initial management should include placing the
infant on cardiorespiratory monitoring, with vital sign monitoring and clinical
reassessments. Normal saline boluses may be given in cases of hypoperfusion and
shock. Blood pressure stabilization with pressors may be needed. In some cases
hydrocortisone may be required. Hypothermia should be corrected by gradual

warming of the baby. Hypoglycemia and electrolyte abnormalities should also be
corrected. Oxygen, humidified nasal cannula, or other respiratory support may be
needed for neonates with apnea or respiratory distress.
Antibiotics should be given as soon as possible. Whenever feasible, cultures
should be obtained before starting antibiotics. Obtaining cultures and starting
antibiotics are a priority. Lumbar puncture may be delayed if the baby is unstable.