Neonatal Sepsis
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Direct answer
Refusing the breast in a newborn who fed well yesterday, with cold extremities and falling urine output, is sepsis until blood culture proves otherwise — the signs are subtle, not dramatic. Early-onset sepsis, within 72 hours, is acquired from the maternal genital tract (group B streptococcus, Escherichia coli, Listeria); late-onset, after 72 hours, comes from the environment and hands (Staphylococcus, Klebsiella, Candida). Empirical therapy for early-onset disease is ampicillin or penicillin with gentamicin, started after blood culture but without waiting for its result.
What you must remember
- Risk factors for early-onset sepsis: rupture of membranes beyond 18 hours, maternal fever or chorioamnionitis, foul liquor, prematurity and low birth weight.
- The clinical picture: poor feeding, lethargy, hypothermia (more often than fever), apnoea, fast breathing, abdominal distension, prolonged capillary refill, jaundice and sclerema — a normal temperature never excludes sepsis.
- Investigations: blood culture is the gold standard; CRP rises after 6–8 hours and is useful as a trend; an immature-to-total neutrophil ratio above 0.2, thrombocytopenia, hypoglycaemia and metabolic acidosis all support the diagnosis.
- Lumbar puncture is attempted in every sick neonate unless contraindicated — meningitis accompanies a significant share of positive cultures and changes drug choice and duration.
- Empirical antibiotics: early onset, ampicillin or penicillin plus gentamicin; late onset, an anti-staphylococcal agent such as vancomycin with an aminoglycoside; meropenem with vancomycin is reserved for multidrug-resistant unit flora.
- Duration is 10–14 days for sepsis and at least 21 days for gram-negative or staphylococcal meningitis; antibiotics stop at 48 hours if the culture is sterile and the baby well.
- Supportive care decides survival: warmth, oxygen and ventilation as needed, fluids and glucose, and a 10 mL per kg normal saline bolus for shock.
- Prevention: clean delivery and cord care, strict hand hygiene, exclusive breastfeeding; routine intrapartum group B streptococcus prophylaxis is not national policy in India.
A typical exam case
A five-day-old 2.1 kg baby, born after membranes were ruptured for a day, is brought with poor feeding for 12 hours and cold hands. Temperature 35.6°C, respiratory rate 68 with grunting, capillary refill 3 seconds, abdominal distension. The sequence: oxygen for the grunting, access and a blood culture drawn before antibiotics, then a lumbar puncture once stable, CRP and counts sent alongside. At day five, unit-acquired staphylococci and Klebsiella are as likely as maternal-tract organisms, so many units would start an anti-staphylococcal regimen rather than plain ampicillin-gentamicin. A 20 mL per kg saline bolus treats the shock; a dextrose check catches the hypoglycaemia that walks with sepsis. Culture grows Klebsiella sensitive to the empirical pair, feeding resumes by day 3 of therapy, and the course runs 14 days — 21 with a month of daily weights had the cerebrospinal fluid been abnormal.
Where students slip
Expecting an adult-type presentation is the recurring slip — a neonate with sepsis hypotherms rather than spikes, sulks rather than rigs, and a "well-looking" baby with poor feeding at 20 hours is already an emergency. The second is delaying antibiotics for a better sample: one culture before the first dose, then therapy. Third, forgetting the lumbar puncture, so a meningitis gets 10 days of treatment and relapses. Fourth, escalating straight to carbapenems as first-line — meropenem is a resistant-unit drug, and casual use breeds the resistance that makes Indian neonatal units so difficult. Finally, remember platelets: thrombocytopenia in a sick neonate is a sepsis sign, not a haematology curiosity.
Frequently asked questions
How is early-onset sepsis differentiated from late-onset?
Early onset presents within 72 hours with maternal-tract organisms (group B streptococcus, E. coli, Listeria); late onset after 72 hours with hospital or community flora such as Staphylococcus, Klebsiella and Candida.
Which investigations support neonatal sepsis?
Blood culture is definitive; CRP, an immature-to-total neutrophil ratio above 0.2, thrombocytopenia, hypoglycaemia and metabolic acidosis are supportive, and lumbar puncture excludes meningitis.
What is the empirical antibiotic combination for early-onset sepsis?
Ampicillin or penicillin with gentamicin, started after blood culture but before results; the regimen is refined when the organism and sensitivity return.
Why is fever absent in many septic neonates?
Thermoregulation is immature, so infection more often produces hypothermia or a normal temperature; waiting for fever to suspect sepsis delays treatment dangerously.
How long are antibiotics given for neonatal meningitis?
At least 14 days for group B streptococcus and 21 days for gram-negative or staphylococcal meningitis, guided by course and, where doubt persists, a repeat lumbar puncture.
Can antibiotics be stopped if cultures are negative?
Yes — a sterile culture at 48 hours in a clinically well baby justifies stopping empirical therapy, a key stewardship point in Indian units.