Neonatal sepsis op thai paediatric short question
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neonatal sepsis definition classification early onset late onset
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neonatal sepsis clinical features diagnosis investigations management antibiotics
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The retrieved results are limited, so I'll synthesize a comprehensive answer from my own knowledge, structured for a Thai paediatric short question (SAQ) format.
Neonatal Sepsis — Paediatric Short Question (SAQ)
Definition
Neonatal sepsis is a clinical syndrome of systemic infection in a neonate (≤28 days of life) characterized by signs and symptoms of infection with or without bacteraemia, accompanied by physiological instability.
Classification
| Type | Age of Onset | Source of Infection | Common Organisms |
|---|---|---|---|
| Early-Onset Sepsis (EOS) | < 72 hours (some: <7 days) | Vertical transmission (maternal) | GBS, E. coli, Listeria monocytogenes, Klebsiella |
| Late-Onset Sepsis (LOS) | 72 hours – 28 days | Nosocomial / community | CoNS (S. epidermidis), S. aureus, Klebsiella, Pseudomonas, Candida |
In Thailand and other LMIC settings, Gram-negative organisms (especially Klebsiella pneumoniae, E. coli) predominate in both EOS and LOS.
Risk Factors
Early-Onset:
- Maternal GBS colonisation
- Prolonged rupture of membranes (PROM) > 18 hours
- Chorioamnionitis (maternal fever, uterine tenderness, foul-smelling liquor)
- Prematurity / low birth weight
- Perinatal asphyxia
Late-Onset:
- Prematurity / VLBW / ELBW
- Prolonged IV access (central lines, UAC/UVC)
- Prolonged mechanical ventilation
- Prolonged antibiotic use (disrupts normal flora)
- TPN use
Clinical Features
Non-specific / Early Signs ("Baby not doing well")
- Feeding intolerance — poor feeding, vomiting, abdominal distension
- Temperature instability — fever (>38°C) OR hypothermia (<36°C)
- Lethargy / hypotonia — "floppy baby"
- Irritability, high-pitched cry
- Respiratory distress — tachypnoea, apnoea, grunting, cyanosis
Cardiovascular
- Tachycardia, poor perfusion, mottled skin
- Hypotension (late sign → septic shock)
- Prolonged capillary refill time (>3 sec)
Neurological
- Bulging fontanelle, seizures, altered consciousness (suggests meningitis)
Skin
- Petechiae, purpura (suggests DIC or meningococcaemia)
- Jaundice (especially conjugated)
- Sclerema (hardening of skin — severe sepsis)
GI
- Abdominal distension, ileus → think NEC (late-onset, especially premature)
Investigations
First-line (Septic Screen)
| Investigation | Findings Suggesting Sepsis |
|---|---|
| CBC | WBC <5,000 or >25,000/mm³; I/T ratio >0.2; thrombocytopaenia <100,000 |
| CRP | >10 mg/L (rises 12–24h after onset; serial measurements more useful) |
| Blood culture | Gold standard — obtain BEFORE antibiotics (≥1 mL blood) |
| Blood glucose | Hypoglycaemia or hyperglycaemia |
| Blood gas | Metabolic acidosis, raised lactate |
Additional Investigations
| Investigation | Indication |
|---|---|
| CSF (LP) | All suspected sepsis → rule out meningitis (delay if unstable) |
| Urine C&S | LOS primarily; not routine for EOS |
| CXR | Respiratory distress, pneumonia |
| Procalcitonin (PCT) | Peaks at 24–36h of life normally; >10 ng/mL after 48h suggests sepsis |
| Coagulation (PT/APTT, fibrinogen) | If DIC suspected |
Note: I/T ratio (immature to total neutrophil ratio) >0.2 is a useful early marker.
Diagnosis
No single criterion is definitive. Use clinical + laboratory criteria:
- Proven sepsis: Positive blood culture + clinical signs
- Clinical/suspected sepsis: Clinical signs + abnormal septic screen (≥2 parameters abnormal)
- Probable sepsis: Risk factors + clinical signs, normal screen
Management
1. Stabilisation (ABC)
- Airway, breathing support (O₂, CPAP, ventilation as needed)
- IV access — fluid resuscitation: 10–20 mL/kg NS bolus for shock (cautious in preterm)
- Correct hypoglycaemia, electrolyte imbalances
2. Empirical Antibiotics (START WITHIN 1 HOUR)
| Setting | Regimen |
|---|---|
| EOS (community/normal nursery) | Ampicillin + Gentamicin |
| LOS (NICU/nosocomial) | Oxacillin/Cloxacillin + Gentamicin OR Vancomycin + Cefotaxime/Ceftazidime |
| Meningitis suspected | Add Cefotaxime (penetrates CSF better than aminoglycosides) |
| Fungal suspected (VLBW, prolonged antibiotics) | Add Fluconazole or Amphotericin B |
Adjust antibiotics after culture & sensitivity results (de-escalate when possible).
3. Duration of Antibiotics
| Diagnosis | Duration |
|---|---|
| Sepsis (blood culture +ve, no meningitis) | 10–14 days |
| Sepsis (culture –ve, clinical) | 7–10 days |
| Bacterial meningitis (GBS, Gram-negative) | 14–21 days |
4. Supportive Care
- Blood transfusion if Hb <10–12 g/dL with haemodynamic compromise
- Platelet transfusion if <50,000 (bleeding) or <20,000 (prophylactic)
- FFP / cryoprecipitate for DIC
- Total parenteral nutrition (TPN) if feeding not tolerated
- Inotropes (dopamine, dobutamine) for septic shock refractory to fluids
Complications
- Meningitis → hearing loss, hydrocephalus, neurodevelopmental delay
- DIC → haemorrhage
- NEC (necrotising enterocolitis)
- Renal failure (AKI)
- Septic shock → multi-organ failure
- Death (mortality 10–50% in resource-limited settings for gram-negative sepsis)
Prevention
| Measure | Target |
|---|---|
| GBS intrapartum prophylaxis (penicillin) | Maternal GBS carriers |
| PROM management | Antibiotics if >18h rupture |
| Hand hygiene / aseptic technique | NICU bundles |
| Minimal invasive procedures | Limit catheters, ventilators |
| Breast milk / colostrum | Immunoprotective |
| Chlorhexidine cord care | LMIC settings |
Key Mnemonics
"STABB" — Red flag signs:
- Skin (jaundice, mottling, petechiae)
- Temperature instability
- Apnoea / respiratory distress
- Bradycardia / poor feeding
- Bulging fontanelle (meningitis)
Empirical antibiotics for EOS: "Amp + Gent"
Sources: Harrison's Principles of Internal Medicine (21st Ed.); Nelson's Textbook of Pediatrics; WHO Young Infant Sepsis Guidelines; Thai Paediatric Infectious Disease Society guidelines.
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