Bird's Eye View of a Neonatologist: Clinical Approach to Emergency Neonatal Infection

Abstract

Though the incidence of neonatal infection in term and near-term infants is relatively low, incidence of infection in preterm very low birth weight infants is as high as 20-30% and may result in neurodevelopmental impairment or mortality. Pediatricians should be familiar with recognition and emergency management of life-threatening neonatal infections, such as congenital pneumonia, early onset sepsis, late onset sepsis, bacterial and fungal meningitis, disseminated neonatal herpes simplex virus (HSV), and HSV meningoencephalitis. For the pediatrician, it is logical to approach the management of these infections by time of onset, i.e., early versus late onset of infection. Perinatal risk factors and simple laboratory tests, such as total white blood-cell count, immature/total ratio, and C-reactive protein are helpful in guiding the decision of antibiotics therapy. Successful management of these critical infections depends upon early diagnosis and timely administration of adequate antibiotics. Empiric antibiotic therapy must cover the most likely pathogens according to the risk factors of each individual neonate, and therapy duration is dependent upon culture results, clinical course, and the microorganism. Future research may focus on developing a practical neonatal sepsis score system based on risk factors and common biomarkers, which are readily available at bedside to make early accurate decisions and achieve better outcomes.

Neonatal Sepsis

“…Early diagnosis, appropriate antibiotic administration, and timely supportive management are the keys to successful treatment [53]. Most cases are attributable to Staphylococcus species and GBS, but about one-third are caused by gram-negative organisms.…”

“…Clindamycin or metronidazole are sometimes added to cover anaerobic organisms in cases of necrotizing enterocolitis. Cefotaxime is commonly reserved for the treatment of infants with meningitis [53]. Infants with risk factors for candidal sepsis should receive fungal empiric therapy [10].…”

“…Treatment with a beta-lactam or beta-lactamase inhibitor combined with an aminoglycoside for Enterobacter, Serratia, or Pseudomonas sepsis is recommended by many experts [53]. Meropenem is recommended for preterm infants with systemic extended-spectrum beta-lactamase infections.…”

“…Consultation with a pediatric infectious disease specialist is warranted for failure of sterilization of the bloodstream (i.e., resistant or atypical organisms) and site-specific infections [50]. The use of pentoxifylline in neonatal sepsis was demonstrated to significantly decrease all-cause mortality during hospital stays in underdeveloped or developing countries, which warrants further investigation in large randomized clinical trials in capable countries [53].…”

“…Hydrocortisone has cytokine-suppressing effects, and may improve patient's cardiovascular status, but has not been -WBC/diff ± CRP at 6-12 h evaluated in prospective randomized clinical trials for the treatment of neonatal septic shock [53]. Immunotherapeutic interventions such as intravenous immunoglobulin (IVIG) infusion, IgMenriched intravenous immunoglobulin, and granulocytemacrophage colony-stimulating factor are not recommended [53].…”