“With improved obstetrical management and evidence-based use of intrapartum antimicrobial therapy,” early-onset neonatal sepsis (defined as onset at age 3 days or younger) is becoming less frequent, the Committee notes in the May issue of Pediatrics, available online now.
Nonetheless, suspected sepsis is still one of the most common diagnoses made in the neonatal ICU. The signs of sepsis are nonspecific, and inflammatory syndromes of noninfectious origin mimic those of neonatal sepsis. Most infants with suspected sepsis recover with supportive care (with or without initiation of antimicrobial therapy), the Committee notes.
The specific challenges for clinicians, they write, are threefold: “(1) identifying neonates with a high likelihood of sepsis promptly and initiating antimicrobial therapy; (2) distinguishing “high risk” healthy-appearing infants or infants with clinical signs who do not require treatment; and (3) discontinuing antimicrobial therapy once sepsis is deemed unlikely.”
The aim of the newly-issued Clinical Report, they say, is to “provide a practical and, when possible, evidence-based approach to the diagnosis and management of early-onset sepsis.”
The Committee notes that the diagnosis and management of neonates with suspected early-onset sepsis are based on scientific principles modified by the “art and experience” of the practitioner. Among the “well-established” concepts related to neonatal sepsis outlined in the report:
Diagnostic tests for early-onset sepsis (other than blood or CSF cultures) are useful for identifying infants with a low probability of sepsis but not at identifying infants likely to be infected.
One milliliter of blood drawn before initiating antimicrobial therapy is needed to adequately detect bacteremia if a pediatric blood culture bottle is used.
Cultures of superficial body sites, gastric aspirates, and urine are of no value in the diagnosis of early-onset sepsis.
Lumbar puncture is not needed in all infants with suspected sepsis (especially those who appear healthy) but should be performed for infants with signs of sepsis who can safely undergo the procedure, for infants with a positive blood culture, for infants likely to be bacteremic (on the basis of laboratory data), and infants who do not respond to antimicrobial therapy in the expected manner.
The optimal treatment of infants with suspected early-onset sepsis is broad-spectrum antimicrobial agents (ampicillin and an aminoglycoside). Once the pathogen is identified, antimicrobial therapy should be narrowed (unless synergism is needed).
Antimicrobial therapy should be discontinued at 48 hours in clinical situations in which the probability of sepsis is low.