Neonatal Sepsis and Meningitis

(<2 months old)

Applicable on Chatinkha Nursery and Paediatric Nursery ward

Important points on examination

Remember signs of neonatal sepsis (and for meningitis) are often non specific

• Respiratory distress
• Poor feeding
• Temperature instability (fever but also hypothermia!)
• Irritability or lethargy
• Apnoea, seizures (can be very subtle)
• Vomiting +/- diarrhea
• Jaundice

Ask about risk factors for early neonatal sepsis

• Maternal fever during labour
• Prolonged rupture of membranes (>24hours)
• Foul smelling amniotic fluid

Find out about HIV exposure - look in the mother's health passport

Causes

Group B streptococcus, E Coli and Klebsiella are the commonest organisms found.
Staphylococcus aureus joint/ bone infection present with reduced limb movement.
Coagulase negative staphylococcal septicaemia presents with non-specific signs, often in a baby who has been admitted for several days

Differential Diagnosis

• Congenital heart disease (especially coarctation of the aorta)
• Inborn error of metabolism
• Gastroenteritis with dehydration
• Non accidental injury

Relevant Investigations

All unwell neonates should have the following

• MPs and PCV
• Blood Sugar if reduced BCS, irritable or lethargic, poor feeding, vomiting or diarrhoea, weight <2.5kg, fits, twitches
• Blood Culture
• Any unwell neonate who does not have a clear focus of infection must have a lumbar puncture
  • If the baby is too sick to tolerate an LP this should be clearly documented
• Consider supra-pubic aspirate for UTI
• Ideally the above investigations should be performed before antibiotics are given, but treatment should not be delayed if this is not possible

Treatment

Supportive Treatment

• (A)irway
  -If necessary, position the airway in the 'neutral position'
• (B)reathing
  -Give O2 if there is significant respiratory distress or cyanosis and scale up to CPAP if sole O2-provision does not improve the baby enough
• (C)irculation
  -If the baby is shocked, give
  10 mls/kg IV bolus Normal Saline or Ringers Lactate
  1. Reassess and repeat until there are no signs of shock
  2. After 3 boluses give blood
• (D)isability
  -If blood sugar is 2.2 mmol or less:
  1. Give 1ml/kg of 50% dextrose PO/NGT
     -OR give 2 mls/kg of 25% dextrose IV (ideally diluted at least 1:1 with normal saline or Ringer's)
     -OR give 5 mls/kg of 10% dextrose IV
  2. Follow with regular feeds (breastfeeding/NGT) or if not tolerating oral intake with an IV line containing dextrose (10% dextrose should be in the final made-up solution for children < 6 mo)

• Keep the baby warm (axillary temperature 36.0-37.0 C).

Drug Treatment

• Following a blood culture and an LP, all babies should be given
  • Penicillin (Xpen) 50 000 IU/kg BD if <7days, QDS if older (IM/IV) and
  • Gentamicin 5mg/kg OD if <7days, 7.5mg/kg OD if older (IM/IV)
• In case of high likelihood (e.g. hazy csf) or confirmed neonatal meningitis:
  • increase the dose of Penicillin (Xpen) to 1000 000 IU/kg BD if <7days, QDS if older (IM/IV)
  • Discuss Ceftriaxone with a senior colleague
• If the baby is very small with little muscle bulk, or there is concern about absorption (e.g. in meningitis) then the IV route should be used
• Paracetamol should be used where necessary to relieve fever (15mg/kg tds)

Continued Treatment/ When to Discharge

• This will obviously be guided by the progress of the baby and results available
• If no obvious focus of infection, check blood culture and CSF results at 48 - 72 hours
  • If both are negative and the baby is well, continue abx until day 5 then discharge
  • If both are negativebut the baby remains sick, then antibiotics should be continued. Further attempts to localize a source of infection (e.g. urine sample) or further diagnoses may need consideration. Consult a senior colleague.
  • If the LP is positive give at least 10 to 14 days of abx.
  • If the blood culture is positive, give at least 7 to 10 days of IM/IV antibiotics (depending upon organism). Consult a senior colleague for further advice.