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Article Last Updated: Aug 18, 2006 Artículo Última actualización: Aug 18, 2006
Coauthor(s): Linda L Bellig, MA, RN, NNP, Track Coordinator, Instructor, Neonatal
Nurse Practitioner Program, Medical University of South Carolina College of Nursing;
Bryan L Ohning, MD, PhD, Clinical Associate Professor of Pediatrics, Medical
University of South Carolina; Medical Director, NICU and Neonatal Transport Team,
Department of Neonatology, Greenville Children's Hospital Coautor (s): Linda L Bellig,
MA, RN, NNP, Coordinador de pista, Instructor, enfermera de práctica neonatal
Programa de Medicina de la Universidad de Carolina del Sur Escuela de Enfermería;
Ohning Bryan L, MD, PhD, Profesor Clínico Asociado de Pediatría, Universidad de
Medicina de Carolina del Sur; Director Médico, UCIN y Equipo de Transporte Neonatal
del Departamento de Neonatología, Greenville Children's Hospital
INTRODUCTION INTRODUCCIÓN
Section 2 of 11 Sección 2 de 11
Authors and Editors Autores y Editores
Introduction Introducción
Clinical Clínica
Differentials Diferencias
Workup Workup
Treatment Tratamiento
Medication Medicación
Follow-up Seguimiento
Miscellaneous Miscellaneous
Multimedia Multimedia
References Referencias
Background Fondo
Neonatal sepsis may be categorized as early or late onset. Sepsis neonatal puede ser
categorizada como principios o de inicio tardío. Eighty-five percent of newborns with
early-onset infection present within 24 hours, 5% present at 24-48 hours, and a smaller
percentage of patients present between 48 hours and 6 days of life. Ochenta y cinco por
ciento de los recién nacidos con inicio temprano de la infección presente en las 24 horas,
5% actual al 24-48 horas, y un menor porcentaje de pacientes presentan entre 48 horas y
6 días de vida. Onset is most rapid in premature neonates. El inicio es más rápido en los
recién nacidos prematuros. Early-onset sepsis syndrome is associated with acquisition of
microorganisms from the mother. A principios de sepsis de aparición de síndrome se
asocia con la adquisición de los microorganismos de la madre. Transplacental infection
or an ascending infection from the cervix may be caused by organisms that colonize in
the mother's genitourinary tract, with acquisition of the microbe by passage through a
colonized birth canal at delivery. Infección transplacentaria o una infección ascendente
desde el cuello del útero puede ser causada por organismos que colonizan a la madre del
tracto genitourinario, con la adquisición de los microbios de paso a través de un canal de
nacimiento colonizados en el momento del parto. The microorganisms most commonly
associated with early-onset infection include group B Streptococcus (GBS), Escherichia
coli, Haemophilus influenzae, and Listeria monocytogenes. Los microorganismos más
comúnmente asociados con la aparición temprana de la infección incluyen Streptococcus
del grupo B (GBS), Escherichia coli, Haemophilus influenzae y Listeria monocytogenes.
Late-onset sepsis syndrome occurs at 7-90 days of life and is acquired from the
caregiving environment. De aparición tardía, síndrome de sepsis se produce en 7-90 días
de vida y se adquiere desde el entorno de asistencia a otras personas. Organisms that have
been implicated in causing late-onset sepsis syndrome include coagulase-negative
staphylococci, Staphylococcus aureus, E coli, Klebsiella, Pseudomonas, Enterobacter,
Candida, GBS, Serratia, Acinetobacter, and anaerobes. Los organismos que han estado
implicados en el origen de aparición tardía, síndrome de sepsis incluyen coagulasa-
negativos estafilococos, Staphylococcus aureus, E coli, Klebsiella, Pseudomonas,
Enterobacter, Candida, GBS, Serratia, Acinetobacter, y anaerobios. The infant's skin,
respiratory tract, conjunctivae, gastrointestinal tract, and umbilicus may become
colonized from the environment, leading to the possibility of late-onset sepsis from
invasive microorganisms. La piel del bebé, las vías respiratorias, conjunctivae, tracto
gastrointestinal, ombligo y puede llegar a ser colonizada desde el medio ambiente, dando
lugar a la posibilidad de aparición tardía de la sepsis microorganismos invasores. Vectors
for such colonization may include vascular or urinary catheters, other indwelling lines, or
contact from caregivers with bacterial colonization. Los vectores de esas colonización
puede incluir vascular o catéteres urinarios, inhabitación otras líneas, o póngase en
contacto con cuidadores de colonización bacteriana.
Pneumonia is more common in early-onset sepsis, whereas meningitis and bacteremia are
more common in late-onset sepsis. La neumonía es más común en los principios de sepsis
de aparición, mientras que la meningitis y la bacteriemia son más comunes a finales de
sepsis de aparición. Premature and ill infants have an increased susceptibility to sepsis
and subtle nonspecific initial presentations; therefore, they require much vigilance so that
sepsis can be identified and treated effectively. Prematuros y recién nacidos enfermos,
tienen una mayor susceptibilidad a la sepsis y sutil presentaciones iniciales inespecíficos,
por lo que requieren mucha vigilancia a fin de que la sepsis puede ser identificada y
tratada con eficacia.
Pathophysiology Fisiopatología
The infectious agents associated with neonatal sepsis have changed over the past 50
years. S aureus and E coli were the most common bacterial infectious hazards for
neonates during the 1950s in the United States. Los agentes infecciosos asociados con la
sepsis neonatal han cambiado en los últimos 50 años. S aureus y E coli son los más
comunes de bacterias infecciosas riesgos para los recién nacidos durante la década de
1950 en los Estados Unidos. Over the ensuing decades, GBS replaced S aureus as the
most common gram-positive organism that caused early-onset sepsis. Durante los
decenios subsiguientes, GBS sustituirá S aureus como el más común gram-positivos
organismo que causaron a principios de sepsis de aparición. During the 1990s, GBS and
E coli continued to be associated with neonatal infection; however, coagulase-negative S
aureus is now more frequently observed. Durante el decenio de 1990, GBS y E coli sigue
siendo asociado a infección neonatal, sin embargo, coagulasa-negativos S aureus es ahora
más frecuentemente observada. Additional organisms, such as L monocytogenes,
Chlamydia pneumoniae, H influenzae, Enterobacter aerogenes , and species of
Bacteroides and Clostridium have also been identified in neonatal sepsis. Organismos
adicionales, tales como L. monocytogenes, Chlamydia pneumoniae, H influenzae,
Enterobacter aerogenes, y las especies de Bacteroides y Clostridium también han sido
identificados en la sepsis neonatal.
Meningoencephalitis and neonatal sepsis syndrome can also be caused by infection with
adenovirus, enterovirus, or coxsackievirus. Meningoencefalitis y sepsis neonatal,
síndrome también puede ser causada por infección con adenovirus, enterovirus, o
coxsackievirus. Additionally, sexually transmitted diseases and viral diseases, such as
gonorrhea, syphilis, herpes simplex virus (HSV), cytomegalovirus (CMV), hepatitis,
HIV, rubella, toxoplasmosis, Trichomonas vaginalis, and Candida species, have all been
implicated in neonatal infection. Además, las enfermedades de transmisión sexual y las
enfermedades víricas, tales como la gonorrea, sífilis, virus herpes simplex (HSV),
citomegalovirus (CMV), hepatitis, VIH, rubéola, toxoplasmosis, Trichomonas vaginalis,
Candida y especies, han sido implicados en infección neonatal. Bacterial organisms with
increased antibiotic resistance have also emerged and have further complicated the
management of neonatal sepsis. Bacteriana organismos con una mayor resistencia a los
antibióticos también han surgido y se han complicado aún más la gestión de la sepsis
neonatal. The colonization patterns in nurseries and personnel are reflected in the
organisms currently associated with nosocomial infection. Los patrones de colonización
en los viveros y el personal se reflejan en los organismos que actualmente está asociada a
infecciones nosocomiales. In today's neonatal intensive care units (NICUs), infants with
lower birth weight and infants who are less mature have an increased susceptibility to
these organisms. En la situación actual de cuidados intensivos neonatales unidades
(NICUs), los bebés con menor peso al nacer y bebés que son menos maduros tienen una
mayor susceptibilidad a estos organismos.
Biofilms are formed on indwelling catheters by the aggregation of organisms that have
multiplied with the protection provided by the adherence to the catheter. Biopelículas se
forman en los catéteres inhabitación de la agregación de los organismos que se han
multiplicado con la protección proporcionada por la adhesión al catéter. Slimes are
produced at the site from the extracellular material formed by the organism, which
provides a barrier to the host defense, as well as antibiotic action, making coagulase-
negative staphylococcal septicemia more difficult to treat. Slimes se producen en el lugar
de la material extracelular formado por el organismo, que proporciona una barrera para la
defensa de acogida, así como antibiótico de acción, haciendo coagulasa-negativos toxina
septicemia más difícil de tratar. The toxins formed by this organism have also been
associated with necrotizing enterocolitis. Las toxinas formado por este organismo
también se han asociado con la enterocolitis necrotizante. In addition to being a cause of
neonatal sepsis, the ubiquitous nature of coagulase-negative Staphylococcus as part of the
normal skin flora makes it a frequent contaminant of blood and cerebrospinal fluid (CSF)
cultures; therefore, a culture growing coagulase-negative Staphylococcus may represent a
contaminated sample rather than true coagulase-negative staphylococcal septicemia.
Además de ser una causa de sepsis neonatal, el carácter omnipresente de coagulasa-
negativos Staphylococcus como parte de la flora normal de la piel lo convierte en un
contaminante frecuente de la sangre y líquido cefalorraquídeo (LCR) las culturas, por lo
que una cultura cada vez más coagulasa-negativos Staphylococcus Mayo representan una
muestra contaminados en lugar de verdaderas coagulasa-negativos toxina septicemia.
In addition to the specific microbial factors mentioned above, a number of host factors
predispose the newborn infant to sepsis. Además de los factores específicos microbiana
se ha mencionado anteriormente, una serie de factores que predisponen a acoger al niño
recién nacido a la sepsis. These factors are especially prominent in the premature infant
and involve all levels of host defense, including cellular immunity, humoral immunity,
and barrier function. Estos factores son especialmente importantes en el recién nacido
prematuro e implicar a todos los niveles de defensa de acogida, incluidos la inmunidad
celular, inmunidad humoral, y la función barrera.
The neonatal neutrophil or polymorphonuclear (PMN) cell, which is vital for effective
killing of bacteria, is deficient in chemotaxis and killing capacity. El neonatal o
neutrófilos polimorfonucleares (PMN) de células, que es vital para la eficacia de
asesinato de bacterias, es deficiente en la quimiotaxis y la capacidad de matar. Decreased
adherence to the endothelial lining of blood vessels reduces their ability to marginate and
leave the intravascular space to migrate into the tissues. Disminución de la adhesión al
revestimiento del endotelio de los vasos sanguíneos reduce su capacidad de marginate y
dejar el espacio intravascular a emigrar en los tejidos. Once in the tissues, they may fail
to degranulate in response to chemotactic factors. Una vez en los tejidos, pueden dejar de
degranulate en respuesta a chemotactic factores. Also, neonatal PMNs are less
deformable; therefore, they are less able to move through the extracellular matrix of
tissues to reach the site of inflammation and infection. Por otra parte, neonatal PMNs son
menos deformables y, en consecuencia, son menos capaces de moverse a través de la
matriz extracelular de los tejidos para llegar al lugar de la inflamación e infección. The
limited ability of neonatal PMNs for phagocytosis and killing of bacteria is further
impaired when the infant is clinically ill. La limitada capacidad de PMNs neonatal para la
fagocitosis y muerte de las bacterias se altera cuando el bebé está clínicamente enfermos.
Lastly, neutrophil reserves are easily depleted because of the diminished response of the
bone marrow, especially in the premature infant. Por último, los neutrófilos son
fácilmente reservas agotadas a causa de la disminución de la respuesta de la médula ósea,
especialmente en el recién nacido prematuro.
Although T cells are found in early gestation in fetal circulation and increase in number
from birth to about age 6 months, these cells represent an immature population. Aunque
las células T se encuentran en la gestación temprana en la circulación fetal y aumento del
número desde el nacimiento hasta alrededor de edad de 6 meses, estas células representan
una población inmadura. These naive cells do not proliferate as readily as adult T cells
when activated and do not effectively produce the cytokines that assist with B-cell
stimulation and differentiation and granulocyte/monocyte proliferation. Estos ingenuos
células no proliferan como fácilmente como adultos cuando las células T activadas y no
producir eficazmente el citoquinas que ayudan a las células B-estimulación y la
diferenciación y de granulocitos / monocitos proliferación. A delay occurs in the
formation of antigen specific memory function following primary infection, and the
cytotoxic function of neonatal T cells is 50-100% as effective as adult T cells. Un retraso
se produce en la formación de antígenos específicos de la función de la memoria después
de la infección primaria, y la función citotóxica de las células T neonatal 50-100% es tan
efectivo como las células T de adultos. At birth, neonates are deficient in memory T cells.
Al nacer, los recién nacidos son deficientes en células T de memoria. As the neonate is
exposed to antigenic stimuli, the number of these memory T cells increases. A medida
que el recién nacido está expuesto a estímulos antigénicos, el número de estas células T
de memoria se incrementa.
Natural killer (NK) cells are found in small numbers in the peripheral blood of neonates.
Natural killer (NK), las células se encuentran en pequeñas cantidades en la sangre
periférica de los recién nacidos. These cells are also functionally immature in that they
produce far lower levels of interferon-gamma upon primary stimulation than do adult NK
cells. Estas células son también funcionalmente inmaduros en el sentido de que producen
muy por debajo de los niveles de interferón-gamma primaria a la estimulación que los
adultos, las células NK. This combination of findings may contribute to the severity of
HSV infections in the neonatal period. Esta combinación de hallazgos pueden contribuir
a la gravedad de las infecciones por HSV en el período neonatal.
The fetus has some preformed immunoglobulin present, primarily acquired through
nonspecific placental transfer from the mother. El feto tiene algunas preformados
inmunoglobulina presente, principalmente adquiridos a través de la transferencia
placentaria inespecífico de la madre. Most of this transfer occurs in late gestation, such
that lower levels are found with increasing prematurity. La mayor parte de esta
transferencia se produce a finales de la gestación, de tal forma que los niveles inferiores
se encuentran con el aumento de la prematuridad. The neonate's ability to generate
immunoglobulin in response to antigenic stimulation is intact; however, the magnitude of
the response is initially decreased, rapidly rising with increasing postnatal age. El recién
nacido de la capacidad de generar inmunoglobulina en respuesta a la estimulación
antigénica está intacta, sin embargo, la magnitud de la respuesta se redujo inicialmente,
que aumentan rápidamente con el aumento de la edad postnatal.
The physical and chemical barriers to infection in the human body are present in the
newborn but are functionally deficient. La física y química barreras a la infección en el
cuerpo humano están presentes en el recién nacido, pero son funcionalmente deficientes.
Skin and mucus membranes are broken down easily in the premature infant. La piel y
membranas mucosas se desglosan fácilmente en el recién nacido prematuro. Neonates
who are ill and/or premature are additionally at risk because of the invasive procedures
that breach their physical barriers to infection. Los recién nacidos que están enfermos y /
o prematuro son, además, en situación de riesgo debido a los procedimientos invasivos
que el incumplimiento de sus barreras físicas a la infección. Because of the
interdependence of the immune response, these individual deficiencies of the various
components of immune activity in the neonate conspire to create a hazardous situation for
the neonate exposed to infectious threats. Debido a la interdependencia de la respuesta
inmune, cada una de estas deficiencias de los distintos componentes de la actividad
inmune en el recién nacido conspirar para crear una situación peligrosa para el recién
nacido expuesto a amenazas infecciosas.
Frequency Frecuencia
The mortality rate in neonatal sepsis may be as high as 50% for infants who are not
treated. La tasa de mortalidad en la sepsis neonatal puede ser tan alto como el 50% de los
lactantes que no son tratados. Infection is a major cause of fatality during the first month
of life, contributing to 13-15% of all neonatal deaths. La infección es una de las
principales causas de mortalidad durante el primer mes de vida, contribuyendo al 13-15%
de todas las muertes neonatales. Neonatal meningitis, a serious morbidity of neonatal
sepsis, occurs in 2-4 cases per 10,000 live births and significantly contributes to the
mortality rate in neonatal sepsis; it is responsible for 4% of all neonatal deaths. Neonatal
meningitis, una grave morbilidad de la sepsis neonatal, se produce en 2-4 casos por cada
10000 nacidos vivos y contribuye significativamente a la tasa de mortalidad en la sepsis
neonatal, es responsable de un 4% de todas las muertes neonatales. In the preterm infant,
inflammatory mediators associated with neonatal sepsis may contribute to brain injury
and poor neurodevelopmental outcomes. En los lactantes prematuros, los mediadores de
la inflamación asociada a la sepsis neonatal puede contribuir a la lesión cerebral y los
pobres resultados del neurodesarrollo.
Race Raza
Black infants have an increased incidence of GBS disease and late-onset sepsis. Negro
lactantes tienen una mayor incidencia de la enfermedad y GBS de aparición tardía sepsis.
This is observed even after controlling for risk factors of low birth weight and decreased
maternal age. Esto se observa incluso después de controlar factores de riesgo de bajo
peso al nacer y la disminución de la edad materna.
Sex Sexo
The incidence of bacterial sepsis and meningitis, especially for gram-negative enteric
bacilli, is higher in males than in females. La incidencia de sepsis bacteriana y la
meningitis, especialmente para los gram-negativos bacilos entéricos, es mayor en
hombres que en mujeres.
Age Edad
CLINICAL CLÍNICA
Section 3 of 11 Sección 3 de 11
Authors and Editors Autores y Editores
Introduction Introducción
Clinical Clínica
Differentials Diferencias
Workup Workup
Treatment Tratamiento
Medication Medicación
Follow-up Seguimiento
Miscellaneous Miscellaneous
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References Referencias
History Historia
The most common risk factors associated with early-onset neonatal sepsis include
maternal GBS colonization (especially if untreated during labor), premature rupture of
membranes (PROM), preterm rupture of membranes, prolonged rupture of membranes,
prematurity, maternal urinary tract infection, and chorioamnionitis. La mayoría de los
factores de riesgo comunes asociados con la aparición temprana de la sepsis neonatal
incluyen la colonización materna GBS (sobre todo si no reciben tratamiento durante el
parto), rotura prematura de membranas (PROM), ruptura prematura de membranas,
rotura prolongada de membranas, prematuridad, la maternidad infección del tracto
urinario, y corioamnionitis.
Risk factors also associated with early-onset neonatal sepsis include low Apgar score (<6
at 1 or 5 min), maternal fever greater than 38°C, maternal urinary tract infection, poor
prenatal care, poor maternal nutrition, low socioeconomic status, recurrent abortion,
maternal substance abuse, low birth weight, difficult delivery, birth asphyxia, meconium
staining, and congenital anomalies. Los factores de riesgo también se asocia con inicio
temprano de la sepsis neonatal incluyen puntuación de Apgar baja (<6 a 1 o 5 min),
fiebre materna superior a 38 ° C, la maternidad infección del tracto urinario, la mala
atención prenatal, la mala nutrición materna, nivel socioeconómico bajo, periódicos el
aborto, el abuso de sustancias materna, bajo peso al nacer, parto difícil, la asfixia,
manchas de meconio, y las anomalías congénitas. Risk factors implicated in neonatal
sepsis reflect the stress and illness of the fetus at delivery, as well as the hazardous
uterine environment surrounding the fetus before delivery. Los factores de riesgo
implicados en la sepsis neonatal reflejar el estrés y la enfermedad del feto durante el
parto, así como el medio ambiente uterino peligrosos que rodean el feto antes del parto.
Late onset sepsis is associated with the following risk factors: prematurity, central venous
catheterization (duration of >10 d), nasal cannula continuous positive airway pressure
use, H2 blocker/proton pump inhibitor use, and gastrointestinal tract pathology. Sepsis de
aparición tardía se asocia con los siguientes factores de riesgo: prematuridad, cateterismo
venoso central (duración de> 10 d), cánula nasal positiva continua en las vías
respiratorias uso de presión, bloqueador H2 / inhibidor de la bomba de protones uso, y
patología del tracto gastrointestinal.
An awareness of the many risk factors associated with neonatal sepsis prepares the
clinician for early identification and effective treatment, thereby reducing mortality and
morbidity. La conciencia de los muchos factores de riesgo asociados con la sepsis
neonatal se prepara para el clínico de diagnóstico precoz y un tratamiento eficaz,
reduciendo así la mortalidad y la morbilidad.
Physical Física
The clinical signs of neonatal sepsis are nonspecific and are associated with
characteristics of the causative organism and the body's response to the invasion. Los
signos clínicos de sepsis neonatal son inespecíficos y se asocian con las características de
la causa y la respuesta del organismo a la invasión. These nonspecific clinical signs of
early sepsis syndrome are also associated with other neonatal diseases, such as
respiratory distress syndrome (RDS), metabolic disorders, intracranial hemorrhage, and a
traumatic delivery. Estos signos clínicos inespecíficos del síndrome de sepsis temprana
también se asocian con otras enfermedades neonatales, tales como el síndrome de
dificultad respiratoria (SDR), trastornos metabólicos, hemorragia intracraneal, y una
traumática del parto. Given the nonspecific nature of these signs, providing treatment for
suspected neonatal sepsis while excluding other disease processes is prudent. Dado el
carácter inespecífico de los síntomas, el tratamiento para la sospecha de sepsis neonatal,
mientras que con exclusión de otros procesos de enfermedad es prudente.
DIFFERENTIALS
Section 4 of 11
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Introduction Introducción
Clinical
Differentials
Workup
Treatment
Medication
Follow-up
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Acidosis, Metabolic
Bowel Obstruction in the Newborn
Coarctation of the Aorta
Congenital Diaphragmatic Hernia
Congenital Lung Malformations
Congenital Pneumonia
Heart Failure, Congestive
Hemolytic Disease of Newborn
Hemorrhagic Disease of Newborn
Hypoglycemia La hipoglucemia
Hypoplastic Left Heart Syndrome
Meconium Aspiration Syndrome
Meningitis, Bacterial
Necrotizing Enterocolitis
Osteomyelitis
Pericarditis, Bacterial
Pulmonary Atresia With Intact Ventricular Septum
Pulmonary Hypertension, Persistent-Newborn
Pulmonary Hypoplasia
Pulmonary Sequestration
Respiratory Distress Syndrome
Single Ventricle
Urinary Tract Infection
WORKUP
Section 5 of 11
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Introduction Introducción
Clinical
Differentials
Workup
Treatment
Medication
Follow-up
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Lab Studies
Imaging Studies
Chest radiographs may depict segmental or lobar infiltrate but they more
commonly reveal a diffuse, fine, reticulogranular pattern, much like what is
observed in RDS. Pleural effusions may also be observed.
A CT scan may be needed late in the course of complex neonatal meningitis to
document obstructive hydrocephalus, the site where the obstruction is occurring,
and the occurrence of major infarctions or abscesses. Signs of chronic disease,
such as ventricular dilation, multicystic encephalomalacia, and atrophy, may also
be demonstrated on CT scan.
Head ultrasonograms in neonates with meningitis may show evidence of
ventriculitis, abnormal parenchymal echogenicities, extracellular fluid, and
chronic changes. Serially, head ultrasonograms can demonstrate the progression
of complications.
Procedures
Lumbar puncture is warranted for early- and late-onset sepsis, although clinicians
may be unsuccessful in obtaining sufficient or clear fluid for all the studies.
Infants may be positioned on their side or sit with support. The insertion site
should be between L3 and L4 in order to be below the lowest point of the spinal
cord in infants. If positive culture results are demonstrated, a follow-up lumbar
puncture is often performed within 24-36 hours after antibiotic therapy is initiated
to document CSF sterility. If organisms are still present, modification of drug type
or dosage may be required to adequately treat the meningitis. An additional
lumbar puncture within 24-36 hours is necessary if organisms are still present.
TREATMENT
Section 6 of 11
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Medical Care
In the United States and Canada, the current approach to treat early-onset neonatal
sepsis syndrome includes combined IV aminoglycoside and expanded-spectrum
penicillin antibiotic therapy. This provides coverage for gram-positive organisms,
especially GBS, and gram-negative bacteria, such as E coli . The specific
antibiotics to be used are chosen on the basis of maternal history and prevalent
trends of organism colonization and antibiotic susceptibility in individual
nurseries.
o If an infection appears to be nosocomial, antibiotic coverage should be
directed at organisms implicated in hospital-acquired infections, including
S aureus, S epidermis, and Pseudomonas species. Most strains of S aureus
produce beta-lactamase, which makes them resistant to penicillin G,
ampicillin, carbenicillin, and ticarcillin. Vancomycin has been favored for
this coverage; however, concern exists that overuse of this drug may lead
to vancomycin-resistant organisms, thereby eliminating the best response
to these resistant organisms. Cephalosporins are attractive in the treatment
of nosocomial infection because of their lack of dose-related toxicity and
adequate serum and CSF concentration; however, resistance by gram-
negative organisms has occurred with their use. Use ceftriaxone with
caution in infants with hyperbilirubinemia because it displaces bilirubin
from serum albumin. Resistance and sensitivities for the organism isolated
from cultures are used to select themosteffectivedrug.
o Aminoglycosides and vancomycin both have the potential to produce
ototoxicity and nephrotoxicity and should therefore be used with caution.
The serum drug level is assessed 48 hours after starting treatment to
determine if levels are within the therapeutic range. The drug dosage or
interval may need to be changed to optimize the drug serum levels. A
serum level may also be warranted if the infant's clinical condition has not
improved to ensure that a therapeutic level has been reached. In addition,
renal function and hearing screening should be considered after
completion of the therapeutic course to determine if any short- or long-
range toxic effects of these drugs have occurred.
o If culture results are negative but the infant has significant risk or clinical
signs for sepsis, the clinician must decide whether to provide continued
treatment. Three days of negative culture results should provide
confidence in the data; however, a small number of infants documented to
have had sepsis by postmortem examination had negative culture results
during their initial sepsis evaluation.
o Management is further complicated if the mother received antibiotic
therapy before delivery, especially if she received the therapy within
several hours of delivery. This may result in negative culture results in an
infant who actually has bacteremia or sepsis. With this in mind, the need
for continued therapy should be based not on a single test, but on a review
of all diagnostic data, including culture results, maternal and intrapartal
risk factors, CSF results, the CBC count and differential radiographs, and
the clinical picture. Treatment for 7-10 days may be appropriate, even if
the infant has negative culture results at 48 hours.
o Infants with bacterial meningitis often require different dosages of
antibiotics and longer courses of treatment. These infants may also require
a different drug that has better penetration of the blood-brain barrier to
achieve therapeutic drug concentrations in the CSF. Perform a follow-up
lumbar puncture within 24-36 hours after antibiotic therapy has been
initiated to determine if the CSF is sterile. If organisms are still present,
modification of drug type or dosage is required to adequately treat the
meningitis. Continue antibiotic treatment for 2 weeks after sterilization of
the CSF or for a minimum of 2 weeks for gram-positive meningitis and 3
weeks for gram-negative meningitis, whichever period is longest.
Chloramphenicol or trimethoprim-sulfamethoxazole has been shown to be
effective in the treatment of highly resistant bacterial meningitis.
Granulocyte transfusion has been shown to be suitable for infants with significant
depletion of the storage neutrophil pool; however, the documentation of storage
pool depletion requires a bone marrow aspiration, and the granulocyte transfusion
must be administered quickly to be beneficial. The number of potential adverse
effects, such as graft versus host reaction, transmission of CMV or hepatitis B,
and pulmonary leukocyte sequestration, is considerable. Therefore, this therapy
remains an experimental treatment.
IVIG infusion has been studied as a possible therapy for neonatal sepsis to
provide type-specific antibodies to improve opsonization and phagocytosis of
bacterial organisms and to improve complement activation and chemotaxis of
neonatal neutrophils; however, difficulties with IVIG therapy for neonatal sepsis
exist. The effect has been transient, and adverse effects associated with the
infusion of any blood product can occur. Dose-related problems with this therapy
decrease its usefulness in neonatal populations. At present, the data do not support
the routine use of IVIG in neonatal sepsis.
Recombinant human cytokine administration to stimulate granulocyte progenitor
cells has been studied as an adjunct to antibiotic therapy. These therapies have
shown promise in animal models, especially for GBS sepsis, but require
pretreatment or immediate treatment to demonstrate efficacy. The use of
granulocyte-macrophage colony-stimulating factor (GM-CSF) and granulocyte
colony-stimulating factor (G-CSF) has been studied in clinical trials, but their use
in clinical neonatology remains experimental.
The infant with sepsis may require treatment aimed at the overwhelming systemic
effects of the disease. Cardiopulmonary support and intravenous nutrition may be
required during the acute phase of the illness until the infant's condition stabilizes.
Monitoring of blood pressure, vital signs, hematocrit, platelets, and coagulation
studies is vital.
Surgical Care
Consultations
Diet
The neonate may need to be given nothing by mouth (NPO) during the first days of
treatment because of gastrointestinal symptoms, feeding intolerance, or poor feeding.
Consider parenteral nutrition to ensure that the patient's intake of calories, protein,
minerals, and electrolytes is adequate during this period. Feeding may be restarted via a
nasogastric tube for the infant with serious compromise. For most infants, breast milk is
the enteral diet recommended by the AAP.
Activity
The infant with temperature instability needs thermoregulatory support with a radiant
warmer or incubator. Once the infant is stable from a cardiopulmonary standpoint,
parental contact is important.
MEDICATION
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Some of the antibiotics commonly used to treat neonatal sepsis syndrome are ampicillin,
gentamicin, cefotaxime, vancomycin, metronidazole, erythromycin, and piperacillin. The
choice of antibiotic agents should be based on the specific organisms associated with
sepsis, sensitivities of the bacterial agent, and prevalent nosocomial infection trends in
the nursery. Viral infections such as herpes and fungal infections can masquerade as
bacterial infections.
A viral infection, such as HSV, may masquerade as bacterial sepsis. At the onset of the
infection, treatment must be initiated promptly to effectively inhibit the replicating virus.
Drug Name Acyclovir (Zovirax)
Description Used for treatment of mucosal, cutaneous, and
Descripción systemic HSV-1 and HSV-2 infections.
20 mg/kg/dose q8h IV; may increase dosing
interval in patients <34 weeks PMA or in
patients with significant hepatic or renal
Pediatric Dose failure
Treatment duration for localized infections is
14 d; for disseminated disease or CNS
infections, treat for 21 d
Contraindications Documented hypersensitivity
Concomitant use of probenecid or zidovudine
Interactions prolongs half-life and increases CNS toxicity
of acyclovir
B - Usually safe but benefits must outweigh
Pregnancy
the risks.
Renal disease, dehydration, underlying
neurologic disease, patients with hypoxia and
hepatic or electrolyte abnormalities
Precautions
Periodic monitoring of CBC count is indicated
Fungal infections can masquerade as bacterial infections and/or may appear at the end of
prolonged antibacterial therapy. Their mechanism of action may involve an alteration of
RNA and DNA metabolism or an intracellular accumulation of peroxide that is toxic to
the fungal cell.
The primary care provider (PCP) should evaluate the infant within one week of
discharge from the hospital. The infant can be evaluated for superinfection and
bacterial colonization associated with antibiotic therapy, especially if the therapy
was prolonged. The PCP should evaluate growth and determine if the feeding
regimen and activity have returned to normal.
If neonatal sepsis was associated with meningitis, prolonged hypoxia,
extracorporeal membrane oxygenation (ECMO) therapy, or brain abscess
formation, the infant should be observed for several years to assess their
neurodevelopment and should receive appropriate early intervention services and
therapies when appropriate.
Transfer
The infant may require transfer to a level III perinatal center, especially if he or
she requires cardiopulmonary support, parenteral nutrition, or prolonged
intravenous access.
Multidisciplinary services available at larger centers may be necessary when
treating an acutely compromised neonate.
Deterrence/Prevention
Complications
With early diagnosis and treatment, infants are not likely to experience long-term
health problems associated with neonatal sepsis; however, if early signs and/or
risk factors are missed, the mortality rate increases. Residual neurologic damage
occurs in 15-30% of neonates with septic meningitis.
Patient Education
For excellent patient education resources, visit eMedicine's Blood and Lymphatic
System Center . Also, see eMedicine's patient education article Sepsis (Blood
Infection) .
MISCELLANEOUS
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Medical/Legal Pitfalls
Delay in diagnosis and initiation of proper treatment may result in morbidity and
mortality.
Failure to provide prophylaxis to women with GBS infection may create liability
if the infant subsequently becomes ill.
Special Concerns
The Joint Commission on Infant Hearing of the AAP recommends that infants
who received aminoglycosides should have audiology screening before discharge.
Screen these infants again at 3 months, but no later than 6 months, to determine
whether damage has occurred.
MULTIMEDIA
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Media file 1: Incidence of early- and late-onset invasive group B Streptococcus (GBS)
disease