AKT · Child health/Neonatal & surgical

Neonatal sepsis

Bloodstream infection in the newborn — early-onset (GBS, E. coli) vs late-onset

Overview

Bloodstream/serious bacterial infection in the newborn. EARLY-onset (72 h) is often hospital-acquired (coagulase-negative staph in line-related infection). Non-specific presentation — a LOW THRESHOLD to investigate and treat with antibiotics is essential.

Recognise

NON-SPECIFIC signs: temperature instability, poor feeding, lethargy, respiratory distress/apnoea, tachycardia, jaundice, hypoglycaemia, irritability/seizures
Early-onset (<72 h): GBS, E. coli; risk factors — maternal GBS, prolonged rupture of membranes, maternal pyrexia/chorioamnionitis, prematurity
Late-onset (>72 h): often line-related coagulase-negative staph (preterm/NICU)

Red flags

Any unwell neonate → treat as sepsis until excluded (it can deteriorate fast); meningitis (bulging fontanelle, seizures)
Septic shock; the well-looking baby can deteriorate rapidly

Differentials & how to tell them apart

HIE / metabolic / cardiaccan mimic — but treat as sepsis until excluded given the stakes

TTN/RDSrespiratory presentations overlap — cover for sepsis

Inborn error of metabolismmetabolic screen if atypical/not responding

Investigations

FBC, CRP, BLOOD CULTURES before antibiotics; lumbar puncture if meningitis suspected/possible; glucose; CXR; surface/urine cultures as indicated. Use the NICE neonatal sepsis risk framework.

Management

Cultures then prompt empirical IV antibiotics (early: benzylpenicillin + gentamicin)

1Have a LOW THRESHOLD: take blood cultures (and consider LP) and start empirical IV antibiotics promptly. Early-onset: benzylpenicillin + gentamicin. Use the NICE risk-factor/clinical-indicator framework to decide who to treat.Gate: Treat the possibly-septic neonate EMPIRICALLY without waiting for confirmation — a well-looking baby can deteriorate fast; review/stop antibiotics at 36-48 h if cultures are negative and the baby is well (CRP-guided)
2Tailor antibiotics to cultures; treat meningitis (longer course); supportive care; GBS prevention (intrapartum antibiotics — see O&G).

Early-onset: IV benzylpenicillin + gentamicin — empirical (covers GBS + Gram-negatives) — start promptly after cultures

Late-onset: broad-spectrum per local policy (cover staph/Gram-negatives) — e.g. flucloxacillin/vancomycin + gentamicin

Supportive care; aciclovir if HSV suspected — fluids, respiratory/circulatory support

Key points

Non-specific signs in a neonate = sepsis until excluded → cultures then prompt benzylpenicillin + gentamicin (early-onset GBS/E. coli). Low threshold; the well baby can crash. Late-onset is often line-related staph.

Monitor & prognosis

Cultures/CRP at 36-48 h; clinical course; stop antibiotics if clear.

Good if treated early; meningitis/shock worsen it.

Source: NICE NG195 (neonatal infection); RCPCH