Septicaemia of the newborn

P36.9

DESCRIPTION

Bacterial or fungal invasion of blood before or after birth, which may spread to involve other organs/systems, e.g. meninges (meningitis), lungs, (pneumonia), bone (osteomyelitis), and kidneys (pyelonephritis).

DIAGNOSTIC CRITERIA

Clinical

The baby usually presents with one or more non-specific clinical sign e.g.:

  • vasomotor changes,
  • abdominal distension,
  • feeding problems,
  • tachycardia,
  • lethargy,
  • organomegaly,
  • jaundice,
  • petechiae,
  • diarrhoea,
  • convulsions,
  • tachypnoea,
  • blood glucose disturbances,
  • temperature disturbances,
  • hypotonia,
  • apnoea attacks,
  • shock,
  • sclerema,
  • anaemia,
  • acidosis,
  • cyanosis.
  • Complications include:
    • septic shock,
    • bleeding tendency,
    • hypoglycaemia,
    • DIC and/or thrombocytopenia,
    • apnoea,
    • metabolic acidosis,
    • convulsions,
    • osteomyelitis,
    • anaemia,
    • respiratory failure,
    • meningitis,
    • necrotising enterocolitis,
    • bronchopneumonia,
    • ileus,
    • cardiac failure,
    • renal failure,
    • dehydration,
    • multi-organ failure.

Investigations

  • Blood and cerebrospinal fluid cultures.
  • Blood count and differential count.
  • C-reactive protein and procalcitonin, if available.

GENERAL AND SUPPORTIVE MEASURES

  • Admit to neonatal high or intensive care facility, if available.
  • Ensure a neutral thermal environment.
  • Start infusion with appropriate IV fluid, e.g. neonatal maintenance solution.
  • Ensure adequate nutrition:
    • enteral feeding where possible, via oro/nasogastric tube after ileus, obstruction, or other contraindications to enteral feeding have been excluded.
    • if enteral feeding is not possible, IV fluids, e.g. neonatal maintenance solution and parenteral nutrition under supervision by paediatrician.
  • Insert naso/orogastric tube.
  • Oxygen to maintain PaO₂ at 60–80 mmHg or oxygen saturation of haemoglobin at 90-94%.
  • Ventilatory support if PaCO₂ exceeds 55 mmHg.
  • Monitor:
    • Body temperature 36.2–36.8° C (axillary or anterior abdominal wall).
    • Maintain blood glucose level of 2.6–6.8 mmol/L.
    • Acid-base status and maintain blood pH of 7.35–7.45.
    • Maintain a haematocrit of 40%.
    • Vital signs and respiration, and maintain blood electrolytes and minerals within their normal physiological ranges.
    • Clinical progress and for the emergence of complications.

MEDICINE TREATMENT

Antibiotic therapy

Be aware of the antibiotic sensitivity/resistance profile of bacterial pathogens in your hospital/community.
Reconsider choice of antibiotic when the results of blood and CSF cultures become available or the child does not improve within 72–96 hours.

Empiric treatment (first line):

  • Aminoglycoside, e.g.:
  • Gentamicin, IV, for 10 days.
    • If < 32 weeks gestation: 5 mg/kg/36 hours in the first week of life.
    • If ≥ 32 weeks gestation: 5 mg/kg/24 hours in the first week of life.
    • Monitor blood levels.

PLUS

  • Ampicillin, IV, 50 mg/kg/dose for 10 days.
    • If age < 7 days: 50 mg/kg 12 hourly.
    • If 7 days – 3 weeks of age: 50 mg/kg 8 hourly.
    • If > 3 weeks of age: 50 mg/kg 6 hourly.

If child is deteriorating on above regimen and there are no culture positive results:

Empiric treatment (second line):

  • Piperacillin/tazobactam, IV for 7 days.
    • If < 7 days of age: 50 - 100mg/kg 12 hourly (1st week of life).
    • If > 7 days of age: 50-100mg/kg 6-8 hourly.

PLUS

  • Amikacin, IV for 7 days.
    • 15 mg/kg/dose 24 hourly.
      (Therapeutic drug monitoring to be done where available).

Note: Shorter durations of therapy should be used where there is there is no culture confirmed infection, and child shows clinical improvement.

Fungal infections

Where fungal septicaemia is demonstrated or suspected:

  • Amphotericin B deoxycolate, IV, 1–1.5 mg/kg/day infusion in 5% dextrose water over 4 hours for 14 days.
    • Monitor renal function and serum potassium.

Anaerobic infections

Where anaerobic infection is likely, e.g. after gastro-intestinal surgery for sepsis, or where intra-abdominal sepsis is suspected:

  • Metronidazole, oral/IV, for 10 days.
    • Loading dose, IV: 15 mg/kg administered over 60 minutes.
    • If ≤ 4 weeks of age: 7.5 mg/kg 12 hourly.
    • If ≥ 4 weeks of age: 7.5 mg/kg 8 hourly.

Note: In patients on piperacillin/tazobactam and amikacin, no additional anaerobic cover needed.

Inotropic support

Mean blood pressure should not be less than the gestational age (weeks) of the infant plus 5–10 mmHg.

If blood pressure is < 60/40 mmHg in term infant or < 50/35 mmHg in pre-term infant:

  • Dopamine, IV, 5–15 mcg/kg/minute as a continuous infusion.
    • Continue with dopamine as long as it is necessary to maintain the blood pressure.

REFERRAL

  • Septicaemia with complications.
  • Septicaemia not responding to treatment.