Does the neonate need a sepsis workup?

Neonatal Sepsis Workup: When to Perform

Yes, a sepsis workup should be performed in any neonate showing signs of septic shock including tachycardia, respiratory distress, poor feeding, poor tone, poor color, tachypnea, diarrhea, or reduced perfusion, particularly with maternal history of chorioamnionitis or prolonged rupture of membranes. 1

Clinical Indicators for Sepsis Workup

High-Risk Clinical Signs

• Tachycardia
• Respiratory distress or tachypnea
• Poor feeding
• Poor tone
• Poor color/perfusion
• Diarrhea
• Temperature instability
• Changes in behavior or pain scores 1

Maternal Risk Factors

• History of chorioamnionitis
• Prolonged rupture of membranes 1

Components of Neonatal Sepsis Workup

Initial Assessment

• Continuous monitoring of vital signs (temperature, heart rate, respiratory rate)
• Pre-ductal and post-ductal pulse oximetry
• Blood pressure monitoring (preferably intra-arterial) 1, 2
• Capillary refill (target ≤2 seconds) 1

Laboratory Evaluation

1. Complete blood count with differential
2. Blood cultures (prior to antibiotic administration)
3. Serum glucose (correct hypoglycemia if present)
4. Serum calcium (correct hypocalcemia if present)
5. Arterial blood gas
6. Serum lactate levels 1, 2

Additional Testing Based on Clinical Presentation

• Cerebrospinal fluid analysis if meningitis is suspected
• Urine culture if urinary tract infection is suspected
• Chest radiograph if respiratory symptoms are present
• Comprehensive wound assessment if skin infections are present 1

Management Algorithm

Immediate Actions (First 5 Minutes)

• Establish airway and provide oxygen if needed
• Establish IV/IO access
• Begin high-flow oxygen if respiratory distress is present 1, 2

Early Resuscitation (First 15 Minutes)

• Administer isotonic fluid boluses (10 mL/kg) up to 60 mL/kg until perfusion improves
• Begin empiric antibiotics (including gentamicin for gram-negative coverage) 1, 3
• Monitor for development of rales or hepatomegaly during fluid resuscitation 1

If Shock Persists (15-60 Minutes)

• Begin inotropic support (dopamine up to 10 μg/kg/min)
• Consider central access if peripheral access inadequate
• For cold shock: titrate central dopamine or epinephrine
• For warm shock: titrate central norepinephrine 1, 2

Antibiotic Considerations

Gentamicin is indicated for bacterial neonatal sepsis and should be considered as initial therapy in suspected or confirmed gram-negative infections 3. In the neonate with suspected bacterial sepsis, a penicillin-type drug is usually indicated as concomitant therapy with gentamicin 3.

Monitoring Response to Treatment

Therapeutic Endpoints

• Capillary refill ≤2 seconds
• Normal pulses with no differential between peripheral and central pulses
• Warm extremities
• Urine output >1 mL/kg/h
• Normal mental status
• Normal blood pressure for age
• Normal glucose and calcium concentrations 1

Pitfalls and Caveats

1. Differential Diagnosis: Important to distinguish septic shock from cardiogenic shock caused by ductal-dependent congenital heart disease. Any neonate with shock and hepatomegaly, cyanosis, cardiac murmur, or differential upper/lower extremity blood pressures should be started on prostaglandin infusion until complex heart disease is ruled out 1.

2. Metabolic Disorders: Inborn errors of metabolism resulting in hyperammonemia or hypoglycemia may simulate septic shock and should be ruled out with appropriate laboratory tests 1.

3. Timing of Antibiotics: Delay in antimicrobial therapy increases mortality. Most research indicates antimicrobial therapy should be started within three hours of presentation, with recent guidelines recommending initiation within one hour 4.

4. Refractory Shock: If shock persists despite appropriate management, consider occult conditions such as pericardial effusion, pneumothorax, hypoadrenalism, hypothyroidism, or ongoing blood loss 1.

5. Monitoring for Deterioration: Neonatal sepsis should be addressed with urgency due to the risk of rapid deterioration, particularly in systemically unwell neonates 1.

By following this systematic approach to evaluation and management, clinicians can improve outcomes in neonates with suspected sepsis, reducing morbidity and mortality associated with this life-threatening condition.