Management of Neonates With Suspected or Proven Early-Onset Bacterial Sepsis

Abstract

With improved obstetrical management and evidence-based use of intrapartum antimicrobial therapy, early-onset neonatal sepsis is becoming less frequent. However, early-onset sepsis remains one of the most common causes of neonatal morbidity and mortality in the preterm population. The identification of neonates at risk for early-onset sepsis is frequently based on a constellation of perinatal risk factors that are neither sensitive nor specific. Furthermore, diagnostic tests for neonatal sepsis have a poor positive predictive accuracy. As a result, clinicians often treat well-appearing infants for extended periods of time, even when bacterial cultures are negative. The optimal treatment of infants with suspected early-onset sepsis is broad-spectrum antimicrobial agents (ampicillin and an aminoglycoside). Once a pathogen is identified, antimicrobial therapy should be narrowed (unless synergism is needed). Recent data suggest an association between prolonged empirical treatment of preterm infants (≥5 days) with broad-spectrum antibiotics and higher risks of late onset sepsis, necrotizing enterocolitis, and mortality. To reduce these risks, antimicrobial therapy should be discontinued at 48 hours in clinical situations in which the probability of sepsis is low. The purpose of this clinical report is to provide a practical and, when possible, evidence-based approach to the management of infants with suspected or proven early-onset sepsis. Pediatrics

A correlação entre procedimentos assistenciais invasivos e a ocorrência de sepse neonatal

“…(12,13) During the five years studied, early sepsis of probable maternal origin stood out with the highest frequency (n=35), being cited in other studies as one of the most common diagnoses at the neonatal intensive care unit and probably related to prenatal care defects. (9,13,14) No epidemiological evidence was found in this study or in the literature to support the increased risk of late sepsis after early sepsis in surviving infants when compared to infants without early sepsis, despite the longer hospitalization, need for invasive care procedures to treat the infection and greater risk of death. (15) Among the infants who developed hospital infections, those who only experienced an episode of late sepsis represented n= 6, against n = 8 for infants who developed late sepsis after an episode of early sepsis (developed both -early and late), totaling 14 infants with reported episodes of late sepsis, much lower than the number of early sepsis cases.…”

Implementation of an Antimicrobial Stewardship Program in a Neonatal Intensive Care Unit

“…Our data highlight the need to focus additional efforts on the approach to EOS, which necessitates improvements in existing guidelines that drive practice. [24][25][26] In particular, more accurate identification of those who require antibiotic therapy is greatly needed. Kiser et al 31 demonstrated that application of the Committee on Fetus and Newborn's guidelines for evaluation and treatment of infants exposed to maternal chorioamnionitis 24 resulted in many well-appearing infants with sterile blood cultures being treated with prolonged antibiotic courses, subjected to invasive procedures, and hospitalized for prolonged periods.…”

Recent Developments and Current Issues in the Epidemiology, Diagnosis, and Management of Bacterial and Fungal Neonatal Sepsis

“…Non-culture-based tests may be more helpful in identifying neonates who are unlikely to have infection, when culture-based methods are inconclusive. 39 …”

“…47 Overall, neutrophil indices seem to be more helpful for excluding infants without infection than for including infants with infection. 39 …”

“…If an organism is not isolated and there is no clinical evidence of infection, most clinicians discontinue antimicrobial therapy after 48 hours. 39 The empiric use of cephalosporins is discouraged due to an increased risk for the development of resistance and candidiasis; however, cephalosporins may be indicated if gram-negative meningitis is suspected. [69][70][71][72] For empiric third-generation cephalosporin therapy in neonates, cefotaxime is preferred over ceftriaxone due to the potential displacement of bilirubin and potential for kernicterus observed with ceftriaxone.…”