Newborn Sepsis Clinical Practice Guideline

Bacterial sepsis continues to be a major cause of morbidity and mortality in newborns. The CDC defines early onset sepsis as a blood or cerebrospinal fluid culture proven infection occuring with the first 7 days of life. The incidence of sepsis has been reduced by the intrapartum antitbiotic prophylaxis for the prevention of early onset group B Streptococcal (GBS) disease to less than 1 case per 1,000 live births. Recent data show that GBS is still the most common pathogen, now occuring more commonly in newborns born to mothers who have negative GBS screening cultures. Other causes of neonatal sepsis include E. coli, other Streptococcus species, Enteroccocus and Staph aureus. Identifying newborns at risk for sepsis remains challenging. Please continue to use clinical judgment when evaluating individual babies. RISK FACTORS FOR SEPSIS INCLUDE (see management below): Chorioamnionitis Infant of multiple births where one newborn has GBS sepsis PROM > 18 hours Intrapartum temperature > 38.0 C GBS positive mother with inadequate treatment (less than 4 hrs) Previous infant with early onset GBS sepsis Additional signs of sepsis may include the following: fetal tachycardia fever hyperbilirubinemia apnea hypoglycemia hypotonia lethargy hypothermia pallor tachypnea grunting bulging fontanelle temperature instability tachycardia abd distention

Infants requiring immediate complete diagnostic evaluation and empiric antibiotic therapy:
1. Infants with Signs or Symptoms of Sepsis regardless of presence or absence of risk factors 2. Well appearing infants with the following risk factors: Chorioamnionitis Infant of multiple births, where one newborn is/has been diagnosed with GBS sepsis Complete diagnostic work up for Sepsis includes: Complete blood count with differential, CRP, Blood Culture, Glucose; repeat CBC, CRPs as appropriate Consider CXR if respiratory symptoms are present and Lumbar Puncture if clinically indicated. Consultation: NICU should be consulted if an infant is undergoing an evaluation for presumed sepsis due to clinical signs/symptoms Infants with blood culture positive sepsis require Neonatology Consultation to help guide further management decisions

Infants requiring diagnostic evaluation or screening (rule out sepsis) for risk factors:
1. 2. 3. 4. Intrapartum temperature > 38.0 C Prolonged Rupture of Membranes > 18 hours GBS positive mother with inadequate treatment Previous infant with early onset GBS sepsis

Screening laboratory evaluation includes: CBC at 8 hours and approximately 24 hours later CRP at 8 hours and approximately 24 hours later

Abnormal labs that may warrant empiric treatment or consultation include*: 1. WBC > 30,000 or < 6,000 2. I/T ratio of > 0.3 3. elevated CRP > 1.0 mg/dL
* regarding laboratory studies, the likelihood of sepsis increases substantially if multiple parameters are abnormal

CLINICAL ALGORITHM to Evaluate Newborn at Risk for Sepsis

ANY OF THE FOLLOWING? SIGNS/SYMPTOMS OF NEONATAL SEPSIS? Yes MATERNAL CHORIOAMNIONITIS? INFANT OF MULTIPLE BIRTH WHERE ONE INFANT HAS GBS SEPSIS No

FULL EVALUATION AND EMPIRIC THERAPY:

CBC w/ Differential, CRP, Blood Culture, Glucose Full treatment will depend on lab studies, Cultures, clinical course Repeat CBC, CRP as appropriate to follow Consider the following pending clinical course: chest film, lumbar puncture, electrolytes, iCa

THERAPY:
Antibiotics (if meningitic dosages are necessary, consult Harriet Lane or Neofax) Ampicillin 50mg/kg/dose STAT and then q 8 hours given IV, or IM initially if access difficult to obtain Gentamicin 4mg/kg/dose STAT and then q 24 hours given IV, or IM initially if access difficult to obtain

OBTAIN BLOOD CULTURE

ANY OF THE FOLLOWING? GBS POSITIVE MOTHER with inadequate IAP* PROLONGED RUPTURE OF MEMBRANES > 18 HOURS MATERNAL TEMPERATURE DURING DELIVERY > 38 F < 37 WEEKS GESTATION C-SECTION IN GBS + MOTHER WITH ROM AND/OR LABOR unless adequate IAP PREVIOUS INFANT WITH EARLY ONSET GBS SEPSIS _______________________________ *IAP= intrapartum antibiotic prophylaxis; IAP is adequate if at least 1 dose of ampicillin, penicillin, or cefazolin is administered > 4 hours prior to delivery. Other antibiotics are considered inadequate no matter how many doses, unless maternal GBS strain is known to be sensitive Yes Yes Yes

CBC OR CRP ABNORMAL?

Full treatment course is a minimum of 7 days and 2 days after normal CRP if utilizing CRP to guide management. Laboratory: If Blood Culture positiveConsult Neonatology (will likely need repeat BC, and LP) Repeat CBC/CRP daily, until normalized Gentamicin levels pre and post 3rd dose

SCREENING:
CBC, CRP AT 8 HOURS OF AGE CBC, CRP APPROXIMATELY 24 HOURS LATER VITALS REMAIN Q 4 THROUGHOUT HOSPITALIZATION OBSERVATION X 48 HOURS or appropriate early follow-up if available

No

ROUTINE NEWBORN CARE:

Note: infant of the GBS + mother with adequate IAP should be observed 48 hours, unless early follow-up is assured.

Algorithms are not intended to replace providers clinical judgement or to establish a single protocol. Some clinical problems may not be adequately addressed in this guideline. As always, clinicians are urged to document management strategies. Last revised July 2010 by the Newborn Nursery GBS sub-committee.