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Ri h d A.
Richard A Polin
P li M.D.
MD
Morgan Stanley Childrens Hospital
Columbia University
Expert Panels on Neonatal Sepsis
CLINICAL REPORT
Early-Onset
infants with suspected early-onset sepsis is broad-spectrum antimicro-
Bacterial Sepsis
bial agents (ampicillin and an aminoglycoside). Once a pathogen is iden-
PPROMpreterm premature rupture of membranes
This document is copyrighted and is property of the American
1-36.
tied, antimicrobial therapy should be narrowed (unless synergism is Academy of Pediatrics and its Board of Directors. All authors
needed). Recent data suggest an association between prolonged empir- have led conict of interest statements with the American
Continuing Education Examination available at http://w ww.cdc.gov/mmwr/cme/conted.html
Academy of Pediatrics. Any conicts have been resolved through
ical treatment of preterm infants (5 days) with broad-spectrum anti- a process approved by the Board of Directors. The American
department of health and human services biotics and higher risks of late onset sepsis, necrotizing enterocolitis, Academy of Pediatrics has neither solicited nor accepted any
abstract
Centers for Disease Control and Prevention
and mortality. To reduce these risks, antimicrobial therapy should be commercial involvement in the development of the content of
Richard A. P
this publication.
discontinued at 48 hours in clinical situations in which the probability
of sepsis is low. The purpose of this clinical report is to provide a The guidance in this report does not indicate an exclusiveNEWBORN
course of treatment or serve as a standard of medical care.
practical and, when possible, evidence-based approach
With improved obstetrical management and Variations, to the manage- evidence-based usecircumstances,
taking into account individual of KEY
may be WORDS
ment of infants with suspected or proven early-onset sepsis. Pediatrics appropriate. early-onset se
intrapartum antimicrobial therapy, early-onset neonatal sepsis is be-
2012;129:10061015 meningitis, ga
coming less frequent. However, early-onset sepsis remains one of the sepsis screen
most common causes of neonatal morbidity and mortality in the pre- body surface
INTRODUCTION prevention str
term population. The identication of neonates at risk for early-onset
Epidemiologa
Clinical Spectrum of Early-onset Neonatal Sepsis
EGB el principal patgeno y E. Coli 2 en frecuencia.
There are ~3300 invasive early-onset sepsis cases and 390 deaths in the
Estimacin anual de 3.300 casos, con una mortalidad del 10%.
United states each year (2005-2008 data).
data)
GBS is the leading pathogen and E coli is second
2/3 E coli isolates are resistant to ampicillin.
CDC
PAI
Observacin
incompleta
(Evaluacin
opcional)
COFN
Observacin
Evaluacin
limitada*
PAI
CDC
incompleta
Evaluacin
limitada
+
HBR
18
h
COFN Observacin
*Cuando observacin no es posible Evaluacin
limitada*
Yes Limited evaluation prophylaxis, if the infant is well-appearing a
t FEFmOJUJPOPGBEFRVBUFJOUSBQBSUVNBOUJC
Either <37 weeks Yesor duration
Observation for 48 hours laxis
of membrane rupture and 0is daysclarified asYes4 hours
gestational age andof IVthe penicillin,
duration
18 hours? Yes Signs of neonatal sepsis? Full diagnostic evaluation*
Mother received intravenous Observation for 48 hours cefazolin
rupture before before delivery
delivery (AII).
wasAntibiotic
<18 hours, All otherthen ag th
therapy
penicillin, ampicillin, tions
be observedare considered
No inadequate
for 48 hours, and nofor purpose
routine dia
* Fullordiagnostic
cefazolin for 4 hoursincludes a blood culture, a complete blood count
evaluation management.
is recommended (BIII). If the infant is well-
before delivery?
(CBC) including white blood cell differential and platelet counts, chest ra-
diograph (if respiratory abnormalities are present), and lumbar puncture (if
t 8FMMBQQFBSJOHJOGBOUTXIPTFNPUIFSIBEBO
either
Maternal <37 weeks
chorioamnionitis? Yes and 0 days Limitedgestational
evaluation age o
patient is stableNoenough to tolerate procedure and sepsis is suspected). GBS prophylaxis
of membrane but received
rupture before no therapy
delivery
Antibiotic or inadequat
was
18
Antibiotic therapy should be directed toward the most common causes of
Morbidity and Mortality Weekly Report
neonatal sepsis, including Yes ampicillin
intravenous Observationfor GBS andhours
for 48 coverage
for infantNoshould
antibiotics canundergo
be managed with observation
a limited evaluation an f
37 weeks and durationwww.cdc.gov/mmwr unless
other organisms
of membrane
(including Escherichia coli and other gram-negative patho- for 48the hoursinfant is <37 weeks and 0 days g
(BIII).
and shouldrupture
Recommendations and Reports November 19, 2010 / Vol. 59 / No. RR-10
gens) take into account local antibiotic resistance patterns.
GBS or membranesindicated were No
<18 hours?
Consultation with obstetric providers is important to determine the level of prophylaxis
The following keyrupturedRoutine 18
changes werehours
clinical befo
caremade fr
Prevention
clinical suspicion of Perinatal
for chorioamnionitis. Group B is diagnosed clini-
Chorioamnionitis which
for
guidelines: case
mother?** a limited evaluation and observa
No
t hours is recommended (BIII).
cally and some of the signs are
Streptococcal Disease nonspecific.
Limited evaluation includes blood culture (at birth) and CBC with differential FBMHPSJUINOPXBQQMJFTUPBMMOFXCPSOT
Yes
and platelets Revised
(at orbirthGuidelines
and/or at 612 Yes
fromhours CDC,of2010 life).
Limited evaluation
t
t 8FMMBQQFBSJOHJOGBOUTXJUIBHFTUBUJPOBMBHFPG
FEFmOJUJPOPGBEFRVBUFJOUSBQBSUVNBOUJ
Either <37 weeks duration
** See table 3 for indications for intrapartum GBS
of membrane rupture
prophylaxis.
Observation for 48 hours whose
laxis is mothers
clarified received
Yes4 hours
as adequate
of IV intrapartu
penicillin,
If signs of sepsis develop, a full diagnostic evaluation should be conducted Motherprophylaxis
received intravenous Observation for 48 hours
18 hours?
and antibiotic therapy initiated. cefazolin do not routinely require
before delivery (AII). All other ag diagnost
If 37 weeks gestation, observation may occur at home after 24 hours if other penicillin,
(CIII). ampicillin,
discharge criteria have been met, access to medical care is readily available, tionsforare
or cefazolin considered inadequate for purpos
4 hours
* Full
anddiagnostic
a person who evaluation
is able to includes
complyafully bloodwith culture, a complete
instructions blood
for home count
observa- management.
before delivery?
tion will
(CBC) be present.
including whiteIfbloodany ofcell these conditions
differential andis not met, the
platelet infant
counts, should
chest ra- Monitoring Implementation
t 8FMMBQQFBSJOHJOGBOUTXIPTFNPUIFSIBEBO
be observed
diograph in the hospital
(if respiratory for at leastare
abnormalities 48present),
hours and until
and discharge
lumbar criteria
puncture (if
are achieved.
patient is stable enough to tolerate procedure and sepsis is suspected). and GBS Impactprophylaxisof
No
but Guidelines
received no or inadequa
Antibiotic
Some experts therapy recommend
should bea directed
CBC withtoward differential and platelets
the most common at causes
age 612 of
hours. sepsis, including intravenous ampicillin for GBS and coverage for antibiotics can be managed with observation
t -PDBMBOETUBUFQVCMJDIFBMUIBHFODJFT
JODPO
neonatal Yes
other organisms (including Escherichia coli and other gram-negative patho- unless
37 weeks the infant
and duration
appropriate groupsisof<37 Observation
weeksforare
hospitals, 48 hours
and 0
days g
encourage
gens) and should take into account local antibiotic resistance patterns. of membrane
or membranes
surveillancerupture for were ruptured
early-onset GBS 18disease
hoursand befo
Consultation with obstetric providers is important to determine the level of
<18 hours?
which
steps tocase
promotea limited evaluation
perinatal GBS disease and preven
observ
clinical suspicion for chorioamnionitis. Chorioamnionitis is diagnosed clini-
cally and some of the signs are nonspecific.
Limited
hoursNoistorecommended
cation reduce the incidence (BIII). of early-onset
evaluation includes blood culture (at birth) and CBC with differential
Continuing Education Examination available at http://w ww.cdc.gov/mmwr/cme/conted.html
CLINICAL REPORT
CorioamnioniOs
materna.
CRPC-reactive protein
for neonatal sepsis have a poor positive predictive accuracy. As a result, CSFcerebrospinal uid
clinicians often treat well-appearing infants for extended periods of time, GBSgroup B streptococci
I/Timmature to total neutrophil (ratio)
even when bacterial cultures are negative. The optimal treatment of PMNpolymorphonuclear leukocyte
infants with suspected early-onset sepsis is broad-spectrum antimicro-
2. Evaluacin
Recin
nacido
asintomOco
37
semanas
con
factor
PPROMpreterm premature rupture of membranes
bial agents (ampicillin and an aminoglycoside). Once a pathogen is iden- This document is copyrighted and is property of the American
tied, antimicrobial therapy should be narrowed (unless synergism is Academy of Pediatrics and its Board of Directors. All authors
HemoculOvo
al
nacer
ATB
amplio
CorioamnioniOs*
Hemograma
PCR
espectro
6-12
horas
de
vida
Evaluacin
HemoculOvo
HemoculOvo
negaOvo
HemoculOvo
negaOvo
posiOvo
EF
normal
EF
normal
Laboratorio
anormal
Laboratorio
normal
Leucocitos Neutrfilos
Are Complete Blood Cell Counts Useful in the Evaluation of Asymptomatic
Neonates Exposed to Suspected Chorioamnionitis?
selected f
masked th
Gregory L. Jackson, William D. Engle, Dorothy M. Sendelbach, Debra A. Vedro, Sue
Josey, Jodi Vinson, Carol Bryant, Gary Hahn and Charles R. Rosenfeld
Pediatrics 2004;113;1173
The online version of this article, along with updated information and services, is
tational ag
as eviden
located on the World Wide Web at:
http://pediatrics.aappublications.org/content/113/5/1173.full.html
for infants
to 3667 w
PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly
publication, it has been published continuously since 1948. PEDIATRICS is owned,
with a ges
Indice I/T Plaquetas
published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
Boulevard, Elk Grove Village, Illinois, 60007. Copyright 2004 by the American Academy
Third, al
of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.
study, th
age at the
vals of te
Downloaded from pediatrics.aappublications.org at Hospital Virgen de la Salud Biblioteca on January 2, 2013
LR we r
smaller s
cases to
FIGURE 2
around th
ROC curves for WBC counts (A), ANCs (B), I/T ratio (C), and platelet counts (D) performed at !72 hours to stratify
Newman et al. Pediatrics 126: 903-90, 2010
according to age at the time of the CBC. unable to
cific comb
Are Complete Blood Cell Counts Useful in the Evaluation of
Asymptomatic Neonates Exposed to Suspected Chorioamnionitis?
Gregory L. Jackson, MD, MBA*; William D. Engle, MD*; Dorothy M. Sendelbach, MD*; Are Complete Blood Cell Counts Useful in the Evaluation of Asymptomatic
Neonates Exposed to Suspected Chorioamnionitis?
Gregory L. Jackson, William D. Engle, Dorothy M. Sendelbach, Debra A. Vedro, Sue
bra A. Vedro, PNP; Sue Josey, PNP; Jodi Vinson, PNP; Carol Bryant, PNP; Gary Hahn, PNP; and Josey, Jodi Vinson, Carol Bryant, Gary Hahn and Charles R. Rosenfeld
Pediatrics 2004;113;1173
Charles R.ofRosenfeld,
Distribution Abnormal MD* Neutrophil Values in Infants Born The online version of this article, along with updated information and services, is
located on the World Wide Web at:
STRACT. Objective. Chorioamnionitis complicates Eight required rehospitalization; none had evidence of
to 10% of pregnancies and increases the risk of neo- bacterial infection. If neutrophil values had been used to
l infection. Women with chorioamnionitis%receive determine duration of%antibiotics,
symptomatic then local costs
asymptomatic % would
asymptomatic
apartum antibiotics, often resulting in inconclusive have increased by $76 000 to $425 000 per year. (Schelonka)
PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly
publication, it has been published continuously since 1948. PEDIATRICS is owned,
(Manroe) published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
Boulevard, Elk Grove Village, Illinois, 60007. Copyright 2004 by the American Academy
natal blood cultures. Peripheral neutrophil values are Conclusions. Single or serial neutrophil values do not
of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.
I/T-3 25% 5%
med in 856 near-term/term neonates who were ex- chorioamnionitis. Pediatrics 2004;113:11731180; intra-
ed to suspected chorioamnionitis. Each received anti- amniotic infection, neutrophil values, complete blood
ics for 48 hours unless clinical infection or positive count, early-onset infection, antibiotic therapy, length of
Jacksonwere
od cultures occurred. Peripheral neutrophils G L et stay,
al Pediatrics 113: 1173, 2004
resource utilization.
sured serially and analyzed using the reference
ges of Manroe et al; an additional analysis of only the
al neutrophil values used the normal ranges of Sche- ABBREVIATIONS. CDC, Centers for Disease Control and Preven-
ka et al. Results of neutrophil analyses were not used tion; CBC, complete blood cell count; ATN, absolute total neutro-
phil count; ATI, immature neutrophil count; I:T, immature neu-
etermine duration of therapy. Fifty percent of asymp- trophil count:absolute total neutrophil count proportion; NBN,
atic neonates were seen postdischarge to ascertain normal newborn nursery; GBS, group B streptococcus.
Recin nacido asintomtico 37 semanas
Factor de riesgo Corioamnionitis
PAI
incompleta
Observacin
o
24-48
horas
BR
18
horas
Laboratorio
normal
Laboratorio
anormal
EF
normal
Alta
a
las
48
horas
HemoculOvo
Evaluacin
Laboratorio
normal
Laboratorio
EF
normal
anormal
No
precisa
ATB
HemoculOvo
posiOvo
HemoculOvo
negaOvo
Suspender
ATB
ConOnuar
ATB
EF
normal
despus
48-72
horas
Puncin
lumbar
Das de tratamiento antibitico
Duration of Antibiotic Therapy
Tratamiento antibitico 5 das, durante los primeros das de vida, ha sido
asociado con incremento de mortalidad, NEC y sepsis neonatal tarda.
Prolonged therapy with antibiotics ( 5days) in the first few days of life
has been associated with increased mortality, NEC and late onset sepsis.
with
3.5
cs
ero Days on Antibiotic
mpared with Infants w
3.0
OR for NEC,
2.5
2.0
1.5
1.0
0.5
Com
Ze
0
1 to 2 3 to 4 5 to 6 7 to 8 9 to 10 >10
Days on Antibiotics
Cotten CM and the NICHD Network Pediatrics 123: 58-66, 2009, Kuppala
VS J Pediatr. 159: 720-25, 2011, Vanaja N J Pediatr. 159: 392-97, 2011
Recomendaciones
Microbiological
Neonatal Sepsis
Corioamnionitis principal factor de riesgo
para sepsis neonatal precoz
22 wk 23 wk 24 wk 25 wk 26 wk 27 wk 28 wk
Histologic 70% 61% 59% 51% 48% 41% 34%
chorioamnionitis
Clinical 28% 26% 20% 19% 19% 15% 14%
chorioamnionitis
Early-onset sepsis 6% 4% 4% 2% 2% 2% 1%
neonatos
34
semanas.
The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pediatrics.aappublications.org/content/113/5/1173.full.html
}
datos
de
laboratorio,
para
ayudar
como
gua
en
la
toma
de
decisiones
a
la
hora
de
iniciar
tratamiento
anObiOco.
Downloaded from pediatrics.aappublications.org at Hospital Virgen de la Salud Biblioteca on January 2, 2013
http://www.dor.kaiser.org/external/DORExternal/research/InfectionProbabilityCalculator.aspx
Puopolo et al 2011
Probability of Neonatal Early-Onset Infection Based on
Maternal Risk Factors for Infants > 34 weeks gestation
http://www.dor.kaiser.org/external/DORExternal/research/InfectionProbabilityCalculator.aspx
Puopolo et al 2011
Conclusiones