Neonatal Sepsis

Neonatal sepsis is a serious clinical condition where a newborn baby experiences a systemic infection, often accompanied by bacteria in the bloodstream, within the first month of life. It is essentially a widespread inflammatory response in the baby's body due to a suspected or confirmed infection. This condition is also sometimes called neonatal septicemia or newborn sepsis. Neonatal sepsis is categorized based on when symptoms appear: Early-Onset Neonatal Sepsis (EONS): This occurs within the first 72 hours of life, though some definitions extend this to the first 7 days. EONS is typically acquired from the mother before or during birth. Late-Onset Neonatal Sepsis (LONS): This occurs after 72 hours of life, or sometimes after 7 days. LONS is usually acquired from the baby's environment after birth, either from the community or within a hospital setting. It is important to note that the exact time cutoff between EONS and LONS can vary slightly between different medical guidelines.

Symptoms

Temperature instability (fever above 38°C or low body temperature below 36.5°C)
Lethargy, decreased activity, or appearing floppy (hypotonia)
Poor feeding or difficulty tolerating feeds
Irritability or fussiness
Rapid breathing (tachypnea)
Pauses in breathing (apnea)
Grunting sounds during breathing
Flaring of the nostrils
Chest wall retractions (skin pulling in between ribs with each breath)
Bluish discoloration of the skin (cyanosis)
Fast heart rate (tachycardia) or slow heart rate (bradycardia)
Poor peripheral perfusion (cool hands and feet, delayed capillary refill)
Low blood pressure (hypotension)
Mottled skin
Altered mental status (e.g., decreased responsiveness)
Seizures
Bulging or full soft spot on the head (fontanelle)
Vomiting
Abdominal distension (swollen belly)
Diarrhea
Yellowing of the skin or eyes (jaundice)
Small red or purple spots on the skin (petechiae, purpura) or skin rashes
Bleeding

Causes & Risk Factors

Early-Onset Sepsis (EONS) is most commonly caused by Group B Streptococcus (GBS) and Escherichia coli. Less common causes include other streptococci, Listeria monocytogenes, and Enterococcus species. These infections are typically passed from the mother to the baby during pregnancy or birth.
Late-Onset Sepsis (LONS) can be caused by different bacteria depending on where the infection is acquired. In healthcare settings, common causes include Coagulase-negative staphylococci (like Staphylococcus epidermidis), Staphylococcus aureus (including MRSA), and various gram-negative bacteria such as Klebsiella, Enterobacter, Pseudomonas aeruginosa, and Serratia marcescens. Fungi like Candida species can also cause LONS. Community-acquired LONS can involve pathogens similar to EONS, as well as Streptococcus pneumoniae and Neisseria meningitidis. LONS pathogens are usually acquired from the environment, caregivers, or medical equipment.
Maternal intrapartum fever (temperature 38°C or 100.4°F or higher during labor)
Maternal Group B Streptococcus (GBS) colonization
Clinically diagnosed chorioamnionitis (infection of the membranes surrounding the baby)
Prolonged rupture of membranes (water breaking 18 hours or more before delivery)
Preterm prelabor rupture of membranes (PPROM)
Previous infant with invasive GBS disease
Prematurity (being born before 37 weeks of gestation) is the most significant risk factor for EONS and LONS
Low birth weight (less than 2500 grams)
Male sex
Prolonged hospitalization, especially in a Neonatal Intensive Care Unit (NICU)
Presence of invasive medical devices (e.g., central venous catheters, breathing tubes, urinary catheters)
Parenteral nutrition (feeding through a vein)
Recent surgery
Delayed enteral feeding (feeding through the digestive tract)

Diagnosis

Diagnosis of neonatal sepsis involves a careful review of maternal and neonatal risk factors, a thorough physical examination of the baby, and specific laboratory tests.
Maternal history, including GBS status, duration of ruptured membranes, presence of fever or chorioamnionitis, and adequacy of intrapartum antibiotic prophylaxis (IAP), is crucial.
Neonatal history, including gestational age, birth events, and the baby's clinical course since birth, is also important.
A physical examination will assess vital signs, blood circulation, breathing effort, neurological status, and skin appearance.
Blood Culture: This is the most important test to confirm a bacterial infection in the bloodstream. A small amount of blood is collected and sent to the lab to grow and identify any bacteria present. Results typically take 36 to 48 hours for final confirmation.
Complete Blood Count (CBC) with Differential: This blood test checks for changes in white blood cell counts, which can suggest an infection, but these findings are not always specific to sepsis.
C-reactive protein (CRP): This blood test measures a marker of inflammation. A normal CRP level at first does not rule out sepsis, so doctors may repeat this test to see if levels change over time.
Cerebrospinal Fluid (CSF) Analysis and Culture (Lumbar Puncture): A lumbar puncture (spinal tap) may be performed to collect fluid from around the spinal cord. This test is essential if meningitis (infection of the brain and spinal cord membranes) is suspected, especially if blood cultures are positive or the baby shows neurological signs.
Urine Culture: This test checks for infection in the urine and is more commonly used when investigating late-onset sepsis.
Chest X-ray: An X-ray of the chest may be done if the baby has breathing problems to check for pneumonia.
Proven Sepsis is confirmed when a specific germ is found in a sterile body fluid like blood or CSF.
Clinical or Suspected Sepsis is diagnosed when a baby shows signs of infection, even if cultures are negative. Treatment is often started based on clinical suspicion alone due to the rapid progression of the illness.
Some hospitals use sepsis risk calculators, especially for babies born at 35 weeks or later, to help assess the risk of sepsis and guide treatment decisions, aiming to reduce unnecessary antibiotic use.

Treatment Options

Immediate treatment with broad-spectrum intravenous (IV) antibiotics is critical for suspected neonatal sepsis and should not be delayed while waiting for test results. This prompt action is often referred to as "time is tissue."
For Early-Onset Sepsis (EONS), standard initial antibiotics typically include ampicillin (to cover bacteria like Group B Streptococcus and Listeria) combined with an aminoglycoside, such as gentamicin (to cover gram-negative bacteria like E. coli).
For Late-Onset Sepsis (LONS) acquired in a healthcare setting, antibiotics are chosen to target common hospital-acquired germs, which may include those resistant to standard treatments. This often involves vancomycin combined with an aminoglycoside or a third-generation cephalosporin (e.g., cefotaxime, ceftazidime). The specific choice depends on local hospital infection patterns.
Once the specific germ causing the infection is identified and its sensitivities to antibiotics are known, the treatment will be adjusted to the most effective and safest antibiotic.
The duration of antibiotic treatment varies: If sepsis is ruled out (blood cultures are negative after 36-48 hours and the baby is clinically well), antibiotics are usually stopped. For proven sepsis (bacteria in the blood), treatment typically lasts 7 to 10 days. For meningitis (infection of the brain and spinal cord membranes), treatment may last 14 to 21 days. For bone or joint infections, treatment can extend to 4 to 6 weeks.
Supportive care is also essential and may include: Respiratory Support: Providing extra oxygen, continuous positive airway pressure (CPAP), or mechanical ventilation if the baby has difficulty breathing. Cardiovascular Support: Administering IV fluids and sometimes medications (inotropes or vasopressors) to support blood pressure and circulation if the baby is in septic shock. Metabolic/Nutritional Support: Correcting blood sugar imbalances, managing acid levels, maintaining fluid and electrolyte balance, and providing nutrition either through a vein or by feeding.

Frequently Asked Questions

What is neonatal sepsis?

Neonatal sepsis is a serious condition where a newborn baby (within the first month of life) develops a widespread infection, often with bacteria in their bloodstream. It means the baby's body is having a strong inflammatory response to a suspected or confirmed infection.

What is the difference between early-onset and late-onset sepsis?

Early-onset neonatal sepsis (EONS) occurs within the first 72 hours (or sometimes 7 days) of life, typically acquired from the mother during pregnancy or birth. Late-onset neonatal sepsis (LONS) occurs after 72 hours (or 7 days) of life, usually acquired from the baby's environment after birth, either at home or in the hospital.

How did my baby get this infection?

Babies with early-onset sepsis usually get the infection from their mother before or during delivery. Babies with late-onset sepsis typically acquire the infection from their surroundings after birth, which can include caregivers, contaminated equipment, or the community.

What is Group B Strep (GBS) and how does it relate to sepsis?

Group B Streptococcus (GBS) is a common type of bacteria that can live in the vagina and rectum of pregnant women without causing symptoms. It is one of the most common causes of early-onset neonatal sepsis, as it can be passed to the baby during birth.

I tested negative for GBS, so why does my baby have sepsis?

While GBS is a common cause, other bacteria can also cause neonatal sepsis. Additionally, GBS screening is not 100% accurate, or your baby may have developed late-onset sepsis from an environmental source after birth, which is not related to your GBS status.

What are the signs of sepsis in a newborn?

Signs of sepsis in a newborn can be subtle and non-specific. They include changes in temperature (fever or low body temperature), lethargy, poor feeding, irritability, breathing difficulties (fast breathing, pauses in breathing, grunting), changes in heart rate, pale or mottled skin, and sometimes seizures or a bulging soft spot on the head.

Why are the symptoms so subtle in a baby?

Newborns, especially premature ones, have immature immune systems and may not show clear signs of infection like older children or adults. Their symptoms can be very subtle and non-specific, making early detection challenging. The infection can also progress very rapidly.

What tests are needed to diagnose sepsis?

Diagnosis involves reviewing your baby's history and physical exam, along with laboratory tests. The most important test is a blood culture to identify bacteria. Other tests include a complete blood count (CBC), C-reactive protein (CRP), and sometimes a lumbar puncture (spinal tap) to check for meningitis, or a chest X-ray for breathing problems.

How long does it take to get the blood culture results?

Blood culture results typically take 36 to 48 hours for final confirmation. However, preliminary results may be available sooner, and treatment often begins before final results are known due to the urgency of the condition.

Why was my baby started on antibiotics before the test results were back?

Because neonatal sepsis can progress very quickly and be life-threatening, doctors often start antibiotics immediately based on clinical suspicion, even before test results confirm an infection. This prompt treatment is crucial to give your baby the best chance of recovery.

What antibiotics are used to treat neonatal sepsis?

For early-onset sepsis, a combination of ampicillin and gentamicin is commonly used. For late-onset sepsis, especially if acquired in the hospital, antibiotics like vancomycin combined with an aminoglycoside or a third-generation cephalosporin may be used. The specific choice depends on the suspected germs and local resistance patterns.

How long will my baby need to be on IV antibiotics?

The duration varies. If sepsis is ruled out and your baby is well, antibiotics may be stopped after 36-48 hours. For proven sepsis, treatment usually lasts 7-10 days. If meningitis is diagnosed, it can be 14-21 days, and for bone or joint infections, it may be 4-6 weeks.

What are the side effects of the antibiotics?

Like all medications, antibiotics can have side effects. Your healthcare team will carefully monitor your baby for any potential side effects and adjust treatment as needed. They can provide specific information about the antibiotics your baby is receiving.

What is a lumbar puncture (spinal tap) and why does my baby need one?

A lumbar puncture, or spinal tap, is a procedure where a small needle is used to collect a sample of cerebrospinal fluid (CSF) from around the baby's spinal cord. This test is important to check for meningitis, an infection of the membranes surrounding the brain and spinal cord, especially if sepsis is confirmed or suspected with neurological symptoms.

What other treatments besides antibiotics are needed for my baby?

In addition to antibiotics, babies with sepsis often need supportive care. This can include help with breathing (oxygen, CPAP, or a ventilator), support for blood pressure and circulation with IV fluids or medications, and maintaining proper fluid balance, blood sugar, and nutrition.

How long will my baby have to stay in the NICU?

The length of your baby's stay in the Neonatal Intensive Care Unit (NICU) depends on the severity of the sepsis, how quickly they respond to treatment, and whether any complications develop. Some babies may only need a few days, while others with more severe infections or complications may require a longer stay.

What are the possible long-term complications of neonatal sepsis?

Severe neonatal sepsis, especially if it leads to meningitis, can sometimes result in long-term complications. These may include neurodevelopmental impairment, cerebral palsy, learning difficulties, seizure disorders, hydrocephalus, and sensory problems like hearing loss or vision impairment.

Will my baby have brain damage or developmental problems?

While many babies recover fully, there is a risk of brain damage or developmental problems, particularly if the sepsis was severe or involved meningitis. Your baby will receive long-term follow-up care, including developmental assessments, hearing, and vision screening, to identify and address any issues early.

What is the chance of my baby surviving this infection?

The chance of survival varies depending on factors like your baby's gestational age, birth weight, the type of germ causing the infection, and access to intensive care. In high-income countries, overall mortality is approximately 10-15%, but it can be higher for premature infants or those with certain types of infections.

How can we prevent this from happening if we have another baby?

For future pregnancies, prevention strategies include universal screening for Group B Streptococcus (GBS) in late pregnancy and administering antibiotics during labor if you are GBS-positive or have other risk factors. Practicing good hygiene and infection control, especially in hospital settings, also helps prevent late-onset sepsis.

Does breastfeeding help prevent or treat sepsis?

Breastfeeding, or feeding with human milk, can help prevent late-onset sepsis. Human milk contains important antibodies and immune factors that protect your baby from infections. It is a protective factor rather than a direct treatment for established sepsis.

What follow-up appointments and tests will be needed after we go home?

After discharge, your baby will need regular follow-up appointments. This typically includes developmental assessments to monitor their progress, as well as hearing and vision screening. Early identification of any potential issues allows for timely intervention and support.