Neonatal sepsis is one of the most significant causes of neonatal morbidity and mortality. It is defined as a systemic inflammatory response syndrome (SIRS) that occurs secondary to infection. SIRS is recognized by the presence of two or more of these signs/symptoms:

• Hypothermia or fever

• Tachypnea or hyperventilation

• Tachycardia

• High or low white blood cell count

Classification

Neonatal sepsis is classified into two patterns according to the time of presentation:

• Early-onset sepsis is an invasive bacterial infection of the blood and/or CSF that occurs within the first 7 days of life.

• Late-onset sepsis occurs at approximately 7 to 30 days of age.

Risk Factors

Maternal

Low socioeconomic status

Late or no prenatal care

Poor nutrition

Substance abuse

Recent acquired sexually transmitted infection, untreated focal urinary infection (urinary tract, vaginal, or cervical, or systemic infection

Malnourishment

Intrapartum

Maternal Fever

Premature rupture of membranes

Chorioamnionitis

Prolonged labor

Preterm labor

Use of fetal scalp electrode

Neonatal

Multiple gestation

Male

Birth asphyxia

Meconium aspiration

Congenital anomalies of skin or mucous membranes

Metabolic disorders (e.g. galactosemia)

Low birth weight

Formula feeding

Prolonged hospitalization

Mechanical ventiliation

Umbilical artery catheterization or use of other vascular catheters

Assessment

Earliest clinical signs of neonatal sepsis are nonspecific and include lethargy, poor feeding, and temperature instability, particularly hypothermia. The following laboratory studies are also used:

• Cultures including blood, CSF, and urine

• Fluids such as urine and CSF can be evaluated by counterimmunoelectrophoresis or latex agglutination to help identify the bacteria

• Complete blood count (CBC)

• Sedimentation rate

• Cytokine assays

• Nucleic acid amplification testing

Interventions

Standard treatment for early-onset sepsis includes ampicillin and an aminoglycoside. Late-onset sepsis is treated with vancomycin and an aminoglycoside. Antepartum viral infection can be treated with antiviral. Breastfeeding or feeding the newborn expressed breast milk from the mother is encouraged.

Nursing Considerations

• Administering medications

• Monitoring IV infusions

• Taking precautions when performing treatments

• Following isolation procedures

• Suctioning is not recommended and can further compromise the infant’s immune status

• Isolation procedures are implemented as indicated

Preventative Measures

Hand hygiene is the single most important measure in preventing the spread of infection. Follow standard precautions and guidelines for space, visitation, and general infection control in areas where newborns receive care.

Group B Streptococcus (GBS)

GBS is a leading cause of perinatal infections including bacteremia, endometritis, chorioamnionitis, urinary tract infections (UTIs). In the newborn, it can cause focal or systemic disease. GBS commonly lives in the human GI and genitourinary tracts. Colonization during pregnancy can be continuous or intermittent (AAP, 2018). The practice of giving prophylactic antibiotics to women in labor who are GBS positive has significantly reduced the incidence and severity of early-onset GBS infection in the newborn. The incidence of early-onset neonatal GBS infection is 0.25/1000 live births (AAP, 2018). Risk factors for the development of early-onset GBS infection include:

• Preterm birth

• Rupture of membranes of more than 18 hours before birth

• Intrapartum maternal fever (>38° C [100.4° F])

• Previous infant with invasive GBS disease

• Maternal GBS bacteriuria during the current pregnancy

• Intraamniotic infection (chorioamnionitis)

• Maternal age less than 20 years old

• Intrauterine fetal monitoring

• African-American ethnicity

Early-onset disease develops during the first 7 days, most often within 24 hours after birth, and usually results from vertical transmission from the birth canal. It manifests as systemic infection or respiratory illness that mimics the symptoms of severe respiratory distress. Infant can rapidly develop pneumonia, shock, or meningitis.  Late-onset GBS infections typically occur from 7 days to 3 months of age. Late-onset infection is associated with meningitis, osteomyelitis, and septic arthritis. The usual treatment is ampicillin in combination with an aminoglycoside. If GBS is identified as the cause of infection, penicillin G alone may be given.

Escherichia coli

E. coli is the second most common pathogen causing sepsis and meningitis in newborns. It can cause a variety of neonatal infections, such as omphalitis, diarrheal illness, pneumonia, peritonitis, UTI, and meningitis. Risk factors for the development of E. coli infections in the newborn include preterm birth, low birth weight, maternal infection, prolonged rupture of membranes. Usual treatment for E. coli infection is ampicillin or an extended-spectrum cephalosporin and an aminoglycoside.

Staphylococcus Aureus

Most staphylococcal infections in the newborn develop after the first 72 hours of life and involve the skin and soft tissue. Conjunctivitis, presenting with purulent eye discharge, is common manifestation of S. aureus infection. Skin lesions are typically small vesicles or pustules that are easily treated with topical antimicrobial agents. More severe bullous eruption due to staphylococcal infection is scalded skin syndrome characterized by widespread bullous lesions that easily rupture. Fever and irritability are also present. S. aureus can cause serious problems, including abscesses, osteomyelitis, endocarditis, and septic arthritis. Initial treatment includes nafcillin and vancomycin until definitive culture results are available.

Chlamydia

Neonatal infection caused by chlamydia trachomatis causes neonatal conjunctivitis. Neonatal chlamydial conjunctivitis, with redness of the eyes, edema of the eyelids, and minimal discharge, develops within a few days to several weeks after birth and usually lasts 1 to 2 weeks. Chlamydial pneumonia usually has a gradual onset, between 2 and 19 weeks of age. Manifestations include tachypnea, otitis media, nasal stuffiness, and coughing. Treated with oral erythromycin or azithromycin.

Gonorrhea

Screening during pregnancy and universal administration of neonatal eye prophylaxis (0.5% erythromycin ophthalmic ointment) during the first hour after birth have helped reduce the rates of neonatal infection, which occurs during birth when the infant is exposed to the mother’s infected cervix. Infection in the neonate presents 2 to 5 days after birth and most often involves the eyes, causing ophthalmia neonatorum. Infants with systemic gonococcal infection require hospitalization and 7 days of IV antibiotic therapy. If the newborn has gonococcal meningitis, 10 to 14 days of treatment is required.

Syphilis

Syphilis is caused by infection with the spirochete Treponema pallidum. Congenital syphilis can cause severe illness, miscarriage, stillbirth, and early infant death. Clinical manifestations of congenital syphilis can include:

• Hepatosplenomegaly

• Snuffles

• Lymphadenopathy

• Mucocutaneous lesions

• Pneumonia

• Osteochondritis

• Pseudoparalysis

• Edema

• Rash

• Hemolytic anemia

• Thrombocytopenia

Treatment of the newborn should be initiated when the diagnosis of congenital syphilis is confirmed or suspected or when maternal treatment status is unknown or not well documented. Infants who are symptomatic or whose mother was untreated or unsatisfactorily treated, should have:

• Lumbar puncture (to evaluate for neurologic involvement)

• CBC

• RPR

• VDRL

• Long-bone radiography prior to treatment

If results of these tests are normal and follow-up is certain, a single intramuscular (IM) dose of penicillin G benzathine is recommended. If results are abnormal or there is concern about appropriate follow-up, a 10-day course of IV aqueous penicillin G or IM penicillin G procaine should be given.

Listeriosis

Listeriosis, caused by L. monocytogenes , is primarily a foodborne infection that can cause maternal and neonatal illness. This can cause:

• Chorioamnionitis

• Endometritis

• Miscarriage

• Preterm birth

• Stillbirth

Manifestations include:

• Sepsis-like symptoms

• Acute respiratory distress

• Pneumonia

• Meningitis

• Myocarditis

Toxoplasmosis

Common ways that humans contract toxoplasmosis include:

• Eating raw or undercooked meats or seafoods

• Working with meat

• Drinking unpasteurized milk

• Handling cat litter that contains feces in which the Toxoplasma parasite was shed

• Exposure to contaminated soil

Clinical manifestations of toxoplasmosis are often difficult to distinguish from other congenital infections. Approximately one-third of newborns have a generalized form of the disease that involves the reticuloendothelial system. Other two-thirds of infected newborns have neurologic signs. Clinical features are three key findings (classic triad):

• Hydrocephalus

• Chorioretinitis

• Cerebral calcifications

Severe toxoplasmosis is associated with:

• Preterm birth

• IUGR

• Microcephaly

• Hydrocephaly

• Microphthalmia

• Chorioretinitis

• CNS calcification

• Thrombocytopenia

• Jaundice

• Fever

• Petechiae

• Maculopapular rash

Infants with congenital toxoplasmosis are treated with pyrimethamine, combined with oral sulfadiazine; folinic acid supplement is used to prevent anemia.