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Neonatal Sepsis

Systemic infection in infant <28 days of life (early-onset <72 h, late-onset ≥72 h), often nonspecific presentation requiring high index of suspicion and empirical antibiotic therapy

Written by: Saygı Hospital Health Guide Editorial Board
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What is Neonatal Sepsis?

Definitions: early-onset sepsis (EOS) = clinical and/or microbiological infection onset <72 hours of life (some definitions <7 days); late-onset sepsis (LOS) = infection onset ≥72 hours to 28 days (or later in preterm infants); very late-onset for infants >28 days still hospitalized; nosocomial sepsis is hospital-acquired.

Pathogenesis: EOS — vertical transmission from maternal genital tract; ascending infection from ruptured membranes, intrapartum colonization of neonate's airways/skin/gut, bacteremia; incomplete immune system allows rapid multiplication and dissemination; LOS — nosocomial via caregiver hands, contaminated equipment (central lines, ventilators), hospital environment, or community sources after discharge; skin/gut flora translocation.

Common pathogens: EOS — Group B Streptococcus (GBS, most common in developed countries with adequate screening/prophylaxis 25-30 percent; 40-50 percent without), Escherichia coli (especially preterm), Listeria monocytogenes (less common, associated with maternal food contamination), other gram-negatives and streptococci; LOS — coagulase-negative staphylococci (CoNS, dominant in preterm with central lines 40-60 percent), Staphylococcus aureus (MRSA possible), Enterococcus, gram-negatives (E. coli, Klebsiella, Pseudomonas), Candida (especially VLBW); term infants often community-acquired viral (RSV, influenza) or urinary source.

Clinical picture: neonates typically show nonspecific symptoms — the 'not doing well' infant — requiring high clinical suspicion; absence of localizing signs does not exclude infection; temperature instability (hypothermia equal or more common than fever), apnea, lethargy, poor feeding, respiratory distress, hypotension.

Symptoms

Temperature instability: hypothermia (<36.5°C) more common in neonates than fever; fever >38°C, but fever less reliable in neonate; temperature swings
Respiratory: tachypnea, grunting, retractions, apnea, cyanosis; increased oxygen requirement
Cardiovascular: tachycardia or bradycardia, hypotension, poor perfusion, cool extremities, weak pulses, prolonged capillary refill, metabolic acidosis
Neurological: lethargy, irritability, poor tone, seizures, bulging fontanelle (meningitis), high-pitched cry
Gastrointestinal: poor feeding, vomiting, diarrhea, abdominal distension, hepatomegaly, jaundice (direct hyperbilirubinemia or hemolysis)
Skin: pallor, mottling, petechiae, purpura (severe sepsis, DIC), omphalitis (umbilical infection), pustules; hypoglycemia or hyperglycemia; metabolic abnormalities

Risk Factors

Prematurity and low birth weight (strongest risk factor for both EOS and LOS; risk inversely proportional to GA)
EOS maternal factors: GBS colonization without adequate intrapartum antibiotic prophylaxis (IAP), chorioamnionitis, maternal fever, prolonged rupture of membranes >18 hours, preterm labor/delivery, prior GBS-affected infant
EOS neonatal factors: difficult delivery with resuscitation, birth trauma, meconium-stained fluid
LOS factors: prematurity, prolonged NICU stay, central venous catheters, peripherally inserted central catheters (PICC), mechanical ventilation, surgical procedures, H2-blocker/PPI use, TPN, poor skin barrier
Genetic: congenital immune deficiencies (severe combined immunodeficiency, chronic granulomatous disease — rare but consider with unusual or recurrent infections)
Community factors: household contacts with recent infection; daycare attendance (late LOS)

When to See a Doctor?

If you experience any of the following symptoms, seek medical attention promptly:

  • Any neonate with nonspecific symptoms ('not doing well') — high index of suspicion warranted; EOS evaluation triggered by maternal risk factors (chorioamnionitis, inadequate GBS prophylaxis, prolonged ROM) even in apparently well-appearing infants per hospital protocols; LOS evaluation for any hospitalized or recently discharged infant with signs of infection.
  • Warning signs needing immediate evaluation: temperature <36.5°C or >38°C, apnea, respiratory distress, tachycardia >180 or bradycardia <100, hypotonia, seizures, bulging fontanelle, petechiae, feeding intolerance, jaundice at <24 hours of age, hypoglycemia, metabolic acidosis, new-onset oxygen requirement — bring infant for immediate evaluation.
  • Outpatient infant <90 days old with fever ≥38°C (rectal): requires urgent evaluation (full sepsis workup including blood culture, urinalysis/culture, lumbar puncture for <28 days or high-risk older infants; often hospitalization and empirical antibiotics until cultures negative).

Treatment Methods

01
Prevention: EOS — GBS screening at 35-37 weeks gestation, intrapartum antibiotic prophylaxis (penicillin or ampicillin) for GBS-positive or unknown status with risk factors; treatment of maternal intrapartum infections; antibiotic prophylaxis for prolonged ROM per protocol; LOS — strict hand hygiene, minimize central line days, use of chlorhexidine for catheter insertion/maintenance, aseptic technique, limit H2-blockers/PPIs, promote mother's own milk (reduces NEC/LOS), skin-to-skin care, avoid overcrowding.
02
Initial evaluation: CBC with differential (I/T ratio, absolute neutrophil count), CRP/procalcitonin (serial if used), blood culture (minimum 1 mL, ideally 2 sites if line in situ), urine culture (especially for infants ≥72 hours or indicated by clinical picture), CSF analysis including culture (lumbar puncture indicated if meningitis suspected, positive blood culture, sick neonate requiring broad-spectrum antibiotics), chest radiograph if respiratory symptoms, other cultures per clinical indication (tracheal aspirate, skin, wound).
03
Empirical antibiotic therapy — EOS: ampicillin 100-150 mg/kg/dose every 8-12 h + aminoglycoside (gentamicin 4 mg/kg/dose every 24 h for term, 4-5 mg/kg/dose every 24 h for preterm adjusted for PMA); alternative ampicillin + cefotaxime for suspected gram-negative/meningitis; LOS: vancomycin 10-15 mg/kg/dose every 8-24 h (PMA-adjusted) + aminoglycoside/cefotaxime; add antifungal (fluconazole or micafungin) for high-risk preterm with persistent culture-negative sepsis and candidemia risk; cover for HSV (acyclovir) if seizures, vesicles, or other HSV concerns.
04
Targeted therapy post-culture: narrow based on culture and sensitivity; for specific pathogens — GBS (penicillin or ampicillin 10-14 days bacteremia, 14-21 days meningitis), E. coli (cefotaxime or ceftriaxone with caution re: bilirubin displacement, or meropenem for ESBL), Listeria (ampicillin ± gentamicin), CoNS (vancomycin 7-10 days; consider line removal), S. aureus (MSSA — oxacillin/nafcillin; MRSA — vancomycin; consider linezolid for persistent); duration — uncomplicated bacteremia 7-10 days, pneumonia 10-14 days, meningitis 14-21 days (gram-negative) or 10-14 days (gram-positive).
05
Supportive care: respiratory support (CPAP, ventilation as needed); hemodynamic resuscitation — normal saline 10-20 mL/kg boluses for hypotension, inotropes/vasopressors if refractory (dopamine first-line, epinephrine for shock); glucose monitoring and maintenance; electrolyte/acid-base correction; nutrition (parenteral initially, transition to enteral with mother's own milk); monitor for complications — disseminated intravascular coagulation (DIC), acute kidney injury, hepatic dysfunction, multi-organ failure; treat hyperbilirubinemia (phototherapy).
06
Long-term follow-up: neonatal sepsis especially with meningitis can cause neurodevelopmental sequelae — hearing loss (audiologic screening), neurodevelopmental delay, cerebral palsy, learning disabilities, hydrocephalus (ultrasound follow-up in bacterial meningitis); high-risk infant clinic monitoring; early intervention services; vaccination per schedule; family education on signs requiring return to medical attention; mental health support for family (NICU experience).

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Health Disclaimer: The information on this page is prepared for general informational purposes only. It does not replace medical diagnosis and treatment. Please consult your physician for your complaints. Saygı Hospital does not accept responsibility for actions taken based on the information on this page.