Should all neonates with suspected infection undergo a sepsis workup?

Management of Suspected Neonatal Infections: Sepsis Workup Recommendations

All neonates with suspected infection should undergo a sepsis workup to reduce morbidity and mortality, as early diagnosis and prompt treatment are critical for improving outcomes.

Indications for Sepsis Workup

Clinical Signs Requiring Full Diagnostic Evaluation

• Any neonate with signs of sepsis (tachycardia, respiratory distress, poor feeding, poor tone, poor color, tachypnea, diarrhea, or reduced perfusion) 1
• Full evaluation includes:
  • Blood culture (before antibiotics when possible) 2
  • Complete blood count with differential 1
  • Lumbar puncture for CSF analysis 1
  • Empiric antimicrobial therapy should be started immediately 1

Maternal Risk Factors Requiring Limited Evaluation

• Maternal chorioamnionitis (clinical diagnosis by obstetric provider) 1

  • Limited evaluation includes blood culture and CBC with differential
  • No lumbar puncture required if infant appears well
  • Empiric antimicrobial therapy should be initiated

• Inadequate intrapartum antibiotic prophylaxis (IAP) with:

  • Prolonged rupture of membranes ≥18 hours 1
  • Preterm birth (<37 weeks gestation) 1
  • Limited evaluation includes blood culture and CBC with differential
  • Observation for at least 48 hours

Empiric Antibiotic Therapy

First-Line Regimen

• Ampicillin plus cefotaxime is currently the most recommended empirical regimen for suspected neonatal sepsis 2
• Traditional ampicillin and gentamicin regimens show increasing resistance, especially against Gram-negative bacteria 2
• Dosing:
  • Ampicillin: 50 mg/kg IV every 6 hours 2
  • Cefotaxime: 50 mg/kg IV every 6-8 hours 2

Duration of Therapy

• Culture-negative sepsis: 7-10 days 2
• Culture-positive sepsis: 10-14 days 2
• Bacterial meningitis: 14-21 days 2
• Daily reassessment to consider de-escalation after 48 hours 2

Special Considerations

Preterm Neonates

• Higher risk of sepsis and worse outcomes
• All preterm infants born to women with inadequate IAP should undergo limited evaluation and observation for at least 48 hours 1
• More aggressive diagnostic and therapeutic approach is warranted

Antibiotic Stewardship Concerns

• Prolonged empirical treatment (≥5 days) with broad-spectrum antibiotics in preterm infants is associated with higher risks of late-onset sepsis, necrotizing enterocolitis, and mortality 3
• Discontinue antimicrobial therapy at 48 hours when probability of sepsis is low 3
• Obtain cultures before initiating antibiotics when possible 2

Regional Considerations

• In low and middle-income countries, local antibiograms should guide therapy due to high rates of antimicrobial resistance 1
• Gram-negative pathogens show alarming rates of multi-drug resistance in these settings 1
• Development of robust AMR surveillance and reporting should be prioritized 1

Follow-up and Monitoring

• Schedule follow-up within 24 hours after discharge 2
• Provide clear instructions to parents about concerning symptoms requiring immediate return 2
• Ensure access to emergency care if clinical status changes 2
• Document telephone contact at appropriate intervals after discharge 2

Common Pitfalls to Avoid

1. Delaying antibiotic administration while waiting for diagnostic results
2. Omitting lumbar puncture in symptomatic infants (required for optimal diagnostic sensitivity) 1
3. Continuing empiric antibiotics beyond 48 hours without evidence of infection
4. Failing to distinguish between neonatal sepsis and other conditions (e.g., transient tachypnea, congenital heart disease) 1
5. Not considering local antimicrobial resistance patterns when selecting empiric therapy

By following these recommendations, clinicians can ensure appropriate evaluation and management of neonates with suspected infection, balancing the need for prompt treatment with antimicrobial stewardship principles.