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Suspect neonatal sepsis in any newborn presenting with hypothermia, respiratory distress, hypoperfusion, or feeding difficulty Any neonate presenting with a concern for infection should be hospitalized until cultures are proven negative Apnea is a common presentation of viral upper respiratory tract infections (including respiratory syncytial virus infection) in a neonate Enteroviral infections are more severe in the neonate than children, resulting in meningitis, acute fulminant hepatitis, and heart failure from myocarditis RELATED CHAPTERS Signs and Symptoms Apnea: Chapter 14 Cyanosis: Chapter 21 Fever: Chapter 31 Septic-Appearing Infant: Chapter 73 Tachycardia: Chapter 77 Medical, Surgical, and Trauma Emergencies Dermatologic Urgencies and Emergencies: Chapter 88 Infectious Disease Emergencies: Chapter 94 The Children’s Hospital of Philadelphia Clinical Pathway ED Clinical Pathway for Evaluation/Treatment of Febrile Young Infants (0–56 Days Old) URL: https://www.chop.edu/clinical-pathway/febrile-infant-emergentevaluation-clinical-pathway Authors: R Scarfone, MD; P Gala, MD; A Murray, MD; M.K Funari, RN; J Lavelle, MD; L Bell, MD; C Jacobstein, MD Posted: August 2010, last revised August 2019 Neonatal Sepsis CLINICAL PEARLS AND PITFALLS Neonatal sepsis should always be considered in any sick newborn presenting with symptoms of respiratory distress, hypotension, electrolyte disturbance, poor feeding, or lethargy Neonatal sepsis often presents with hypothermia Neonates may not react to an infection with fever Avoid ceftriaxone due to its ability to displace bilirubin and aggravate hyperbilirubinemia Neonates with a suspected UTI should have a full sepsis workup and be admitted for intravenous antibiotic therapy Direct hyperbilirubinemia or new onset of jaundice after days of life is suspicious for a neonatal UTI Current Evidence Concern for neonatal sepsis is one of the most commonly encountered clinical situations for newborns in the ED General incidence of sepsis in neonates is approximately 0.98 per 1,000 live births It can be categorized into early onset (occurring in newborns who are less than 72 hours of life) or late onset (occurring between and days of life) Early-onset disease occurs through perinatal or vertical transmission from the mother Early-onset disease is caused by microbial flora present in the vaginal tract (GBS, E coli or other gram-negative bacilli, Staphylococcus aureus, Enterococci, viridans group Streptococci, Group A Streptococci, syphilis, H influenzae , Listeria monocytogenes ) Risk factors for early-onset disease usually relate to perinatal exposures (prolonged rupture of membranes, chorioamnionitis, GBS-colonized mother with inadequate intrapartum antibiotics) Late-onset disease may occur through horizontal transmission from the infant’s environment or caregivers and is caused by environmental flora (Staphylococci, E coli, GBS, and candidiasis) Although more commonly seen in the NICU, risk factors for late-onset disease include prematurity, presence of congenital heart disease, gut pathology, and presence of central catheters Other pathogens causing sepsis include viral (herpes simplex, enterovirus, cytomegalovirus, adenoviruses), fungal (systemic candidiasis), and atypical bacteria (Toxoplasma) agents Neonatal infection induces a systemic inflammatory response which accounts for much of the capillary leak and inflammation associated with the disease Clinical Considerations Clinical Recognition Neonatal sepsis presents within the first weeks of life with symptoms ranging from simply poor feeding to frank respiratory distress and cardiovascular collapse ( Table 96.7 ) Hypothermia from inability to maintain body temperature often occurs in babies with sepsis Symptoms and signs can be very nonspecific and sepsis should be considered as a differential diagnosis in any symptomatic newborn Neonatal sepsis can mimic any disease of the newborn, including cardiac (cardiogenic shock from closure of a patent ductus in ductal-dependent lesions), respiratory, endocrine, and metabolic conditions Viral and systemic fungal infections can have the same signs and symptoms as bacterial sepsis TABLE 96.7 SIGNS AND SYMPTOMS OF NEONATAL SEPSIS