Neonatal sepsis is a frequent cause of neonatal mortality; unfortunately, the symptoms of sepsis are not specific and may be attributed to other, noninfectious, causes. It is, therefore, crucial to pay attention to the risk factors for neonatal sepsis.

For early-onset infections, the maternal status of colonization by microorganisms and associated factors are the most important predictors of sepsis in neonates. Infection by group B streptococcus (GBS) species is the most frequent cause of neonatal sepsis, although the prophylactic antibiotic administration has decreased its incidence. Escherichia coli is another common cause of early-onset infections, followed in frequency by other organisms, such as haemophilus influenzae. Organisms such as GBS can invade the amniotic fluid during labor or through occult tears, and cause chorioamnionitis. Women with premature rupture of membranes are also at high risk for colonization of the amniotic fluid, as are those who have preterm labor. All of the above factors can suggest risk for sepsis in the newborn [1] [2]. In one study, women in preterm labor and with premature rupture of membranes were found to have a 75% incidence of microbial invasion of the amniotic cavity [3].

The most important risk factor for late-onset sepsis is the gestational age at delivery: premature newborns are at increased risk because of a weak immune system, or procedures utilizing invasive devices. The most common agent of late-onset sepsis is the group of coagulase-negative staphylococci, major nosocomial pathogens.

Initial signs of neonatal sepsis include decreased activity, feeding and breathing difficulties, abnormal temperature (too high or too low), and diarrhea or vomiting. Hypoglycemia, hyperglycemia, and metabolic acidosis often accompany sepsis, but also occur in purely metabolic conditions. Pneumonia, whether of intrauterine or intrapartum origin, may not be easy to differentiate from respiratory distress syndrome. Coughing, irregular respiration, decreased breath sounds and other symptoms characterize both diseases. Neurological signs (changes in consciousness, seizures, and others) are characteristic of meningitis, which is the common form of central nervous system infection in neonatal sepsis.

• Fever

  Fever or frequent changes in temperature Breathing rapidly, difficulty breathing, or periods of no breathing (apnea) Poor feeding from breast or bottle Decreased or absent urination Bloated abdomen Vomiting yellowish material Diarrhea Extreme redness [lahey.org]

  Infants rarely present with fever unless born to a febrile mother, although some acquire fever immediately after delivery. It is more common for an infant to be hypothermic or present with pneumonia, two nonspecific signs of sepsis. [arupconsult.com]

  Risk Factors: Early onset Sepsis Major Maternal prolonged Rupture of Membranes 18-24 hours Intrapartum Maternal Fever 38 C ( 100.4 F) Chorioamnionitis Sustained Fetal Tachycardia 160 beats per minute Minor Intrapartum Maternal Fever 37.5 C ( 99.5 F) Twin [fpnotebook.com]

• Cerebral Palsy

  Brain damage Cognitive impairments Cerebral palsy Edema (fluid buildup in the brain) Brain abscesses (pus-filled pockets) Cerebral palsy Developmental delays Seizure disorders Learning disabilities What Are the Signs and Symptoms of Neonatal Sepsis and [michigancerebralpalsyattorneys.com]

  Chorioamnionitis as a risk factor for cerebral palsy: A meta-analysis. [scielo.br]

  Antenatal, Intra Partum, and Neonatal Risk Factor for Cerebral Palsy in Children in Podlaskie Province. Journal of Polish Society of Child Neurology. 2009; 18: 19-24. Schlapbach LJ, Aebischer M, Adams M, et al. [jkb.ub.ac.id]

  Sepsis associated with meningitis may lead to the following complications [21] : Cerebral palsy Developmental delay Hearing loss Seizures Neonatal Sepsis Incidence Statistics It is considered an uncommon condition, occurring in 2 to 4 out of every 1000 [pregmed.org]

• Pallor

  One study, 56 which included all neonates, could not find a significant association between pallor and sepsis. Another multicenter study, 45 which also included all neonates, clustered pallor and/or mottling under impaired peripheral perfusion. [pediatrics.aappublications.org]

  […] signs with poor feeding Splenomegaly Neurologic Activity decreased or lethargy Irritability Tremor, jitteriness or Seizure Hyporeflexia or hypotonia High pitched cry Swelling of Fontanel Cardiovascular Hypotension Metabolic Acidosis Tachycardia Skin Pallor [fpnotebook.com]

  General features of neonatal sepsis Pallor, lethargy, jaundice Fever, hypothermia, temperature instability. Note: One-third of confirmed sepsis cases are normothermic. [www2.health.vic.gov.au]

• Fulminant Sepsis

  Fulminant sepsis due to group B β-hemolytic streptococci following transcervical chorionic villi sampling [Letter]. Clin Infect Dis 1993 ; 17 : 142 -143. Wilkins I, Mezrow G, Lynch L, Bottone EJ, Berkowitz RL. [clinchem.aaccjnls.org]

• Pneumonia

  Full Text Dear Editor, Streptococcus pneumoniae (pneumococcus) is a microorganism with high morbidity in children, especially when related with the respiratory tract (in the form of pneumonia) and as a focus of infection in the otorhinolaryngological [archbronconeumol.org]

  Both organisms produce diseases with many features in common, especially fulminant courses with respiratory distress and pneumonia, and often have a fatal outcome. ( AJDC 1986;140:117-121) [jamanetwork.com]

  Abstract Infections (including sepsis, meningitis, pneumonia and tetanus) stand as a major contributor to neonatal mortality in Haiti (22%). [tropej.oxfordjournals.org]

  Early-onset neonatal sepsis Different kinds of bacteria, including Listeria, E.coli ( Escherichia coli ), Group B Streptococcus, Haemophilus influenza and Klebsiella pneumonia are generally responsible for this infection. [pregmed.org]

• Respiratory Insufficiency

  Respirations can become shallow as respiratory insufficiency develops creating risk of acute respiratory failure. [rnpedia.com]

• Decreased Breath Sounds

  Coughing, irregular respiration, decreased breath sounds and other symptoms characterize both diseases. [symptoma.com]

• Abdominal Distension

  The patient had no history of hematemesis, jaundice, abdominal distension or abdominal pain. There was no family history for coagulation disorders. At admission the complete blood count was normal and the inflammatory markers were negative. [termedia.pl]

  distension, blood in stool, increase in quantity of residual mass in stomach); Neurological symptoms; Cardiorespiratory dysfunction (100 180, 30 60, hypotension, time of capillary filling 4 sec); Respiratory symptoms (toughening of parameters of lungs [intechopen.com]

  Gastrointestinal (GIT) symptoms poor feeding vomiting abdominal distension feed intolerance bilious aspirates/vomits loose stools. Central nervous system (CNS) symptoms lethargy irritability seizures. [www2.health.vic.gov.au]

  Hepatomegaly, splenomegaly, abdominal distension. Hypothermia, hyperthermia. Exclusion criteria Babies with the following signs and symptoms: Congenital infection. Early neonatal sepsis. Perinatal asphyxia. Congenital anomalies. [mmj.eg.net]

  distension, seizures, decreased motor activity, skin mottling, and hypotension [ 1, 4 ]. [bmcinfectdis.biomedcentral.com]

• Neonatal Jaundice

  The distribution of 70 respondents obtained as much 15 neonates have history neonatal sepsis of which 12 neonatal jaundice and 3 not became neonatal jaundice. [eprints.ums.ac.id]

  Pathological neonatal jaundice can be caused by a number of factors, including: blood group incompatibility;... [evidence.nhs.uk]

  Late diagnosis of neonatal jaundice both increases the severity and complication. [ijp.mums.ac.ir]

  However, there are concerns about high resistance rates, and side effects such as neonatal jaundice have been reported [71]. [journals.plos.org]

• Tachycardia

  Risk Factors: Early onset Sepsis Major Maternal prolonged Rupture of Membranes 18-24 hours Intrapartum Maternal Fever 38 C ( 100.4 F) Chorioamnionitis Sustained Fetal Tachycardia 160 beats per minute Minor Intrapartum Maternal Fever 37.5 C ( 99.5 F) Twin [fpnotebook.com]

  Assessment Patient may manifest Irritability Weakness Temperature above normal level (36 oC) Skin warm to touch Presence of tachycardia (above 160 bpm) Presence of tachypnea (above 60 bpm) WBC elevated Nursing Diagnosis Hyperthermia related to inflammatory [rnpedia.com]

• Hypotension

  […] sepsis is suspected; Instability of body temperature; Gastro-intestinal symptoms (vomiting, abdominal distension, blood in stool, increase in quantity of residual mass in stomach); Neurological symptoms; Cardiorespiratory dysfunction (100 180, 30 60, hypotension [intechopen.com]

  Diarrhea Abdominal Distention Ileus Dehydration signs with poor feeding Splenomegaly Neurologic Activity decreased or lethargy Irritability Tremor, jitteriness or Seizure Hyporeflexia or hypotonia High pitched cry Swelling of Fontanel Cardiovascular Hypotension [fpnotebook.com]

  Cardiovascular system symptoms tachycardia bradycardic episodes poor perfusion hypotension. Cutaneous symptoms petechiae bruising bleeding from puncture sites. [www2.health.vic.gov.au]

• Cardiomegaly

  Imaging Chest XRay Indicated in all cases Evaluate for Pneumonia, cardiomegaly, Pneumothorax Other imaging indicated in specific scenarios CT Head Indicated for suspected Head Trauma Subdural Hematoma may present with findings suggestive of Neonatal Sepsis [fpnotebook.com]

• Hyporeflexia

  F (36 C) Newborn Temperature 99.6 F (37 C) Gastrointestinal symptoms Vomiting Diarrhea Abdominal Distention Ileus Dehydration signs with poor feeding Splenomegaly Neurologic Activity decreased or lethargy Irritability Tremor, jitteriness or Seizure Hyporeflexia [fpnotebook.com]

• Febrile Seizures

  677 Slipped Capital Femoral Epiphysis 679 Femoral Anteversion 680 Patellofemoral Problems 682 OsgoodSchlatter Disease 683 Blounts Disease 684 Genu Valgum 685 Metatarsus Adductus 686 Clubfoot 687 Scoliosis 689 Kyphosis 692 Cervical Spine Problems 693 Febrile [books.google.de]

Early diagnosis is critical for starting therapy. The pathogen should be identified as soon as possible, so that the treatment with broad-spectrum antibiotics, which carries potential risks if continued too long, can be replaced by a regimen using more specific agents. Analysis of the complete blood cell count with differentials, together with cultures of blood, cerebrospinal fluid and urine (the latter only for late-onset sepsis) are performed in suspected cases.

Thrombocytopenia [4] and neutropenia [5] are frequently observed but are not specific signs. The immature to total neutrophil ratio is a more sensitive indicator of sepsis [5]. Sepsis screening panels use a variety of indicators, including leukocyte counts, neutrophil counts and immature to total neutrophil ratios [6]; their positive predictive value is highly diagnostic.

Blood cultures should test for both aerobic and anaerobic bacteria; growth usually occurs within two days. Results from tests using the polymerase chain reaction (PCR) are available in five hours [7]. Testing for herpes simplex virus is also done by PCR in cases where there is a strong indication of infection by the virus.

Of the acute phase proteins, C-reactive protein and procalcitonin have been used most extensively [8] [9]. A raised procalcitonin level 24 hours after birth is a good indicator of sepsis [10].

Analysis of the cerebrospinal fluid shows increased protein concentration and white blood cell count and decreased glucose concentration in case of meningitis. Cerebrospinal fluid culture should be obtained in cases of suspected sepsis if lumbar puncture can be performed. If the culture shows bacterial growth, further samples should be taken to follow the course of the disease and the effectiveness of treatment.

Chest radiography and imaging of the head by computed tomographic scan, magnetic resonance imaging, or ultrasonography are performed as needed.

• Hyponatremia

  […] herpes simplex Pertussis Congenital syphilis Cardiac Disease Congenital heartdisease Supraventricular tachycardia Myocardial infarction Pericarditis Myocarditis Kawasaki disease Endocrine Disorders Congenital adrenal hyperplasia Metabolic Disorders Hyponatremia [obgynkey.com]

• Chlamydia Trachomatis

  Overview Two-tube multiplex plus add-on singleplex for detection of human cytomegalovirus; Streptococcus Group B ; Listeria monocytogenes; Escherichia coli; Staphylococcus aureus; Chlamydia trachomatis; Ureaplasma urealyticum/parvum and internal control [fast-trackdiagnostics.com]

• T Wave Inversion

  Diagnostics: Electrocardiogram (EKG) Indications Tachycardia Cardiac ausultation findings (e.g. cardiac murmur, gallup, rub) Hepatosplenomegaly Technique Consider obtaing EKG at half speed for easier interpretation Expect T Wave Inversion in leads V1 [fpnotebook.com]

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3. Romero R, Quintero R, Oyarzun E, et al. Intraamniotic infection and the onset of labor in preterm premature rupture of the membranes. Am J Obstet Gynecol. 1988 Sep;159(3):661-666.
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5. Engle WD, Rosenfeld CR. Neutropenia in high-risk neonates. J Pediatr. 1984;105(6):982–986.
6. Rodwell RL, Leslie AL, Tudehope DI. Early diagnosis of neonatal sepsis using a hematologic scoring system. J Pediatr. 1988;112(5):761–767.
7. Chan KY, Lam HS, Cheung HM, et al. Rapid identification and differentiation of Gram-negative and Gram-positive bacterial bloodstream infections by quantitative polymerase chain reaction in preterm infants. Crit Care Med. 2009 Aug. 37(8):2441-2447.
8. Vouloumanou EK, Plessa E, Karageorgopoulos DE, Mantadakis E, Falagas ME. Serum procalcitonin as a diagnostic marker for neonatal sepsis: a systematic review and meta-analysis. Intensive Care Med. 2011;37(5):747–762.
9. Philip AG. Response of C-reactive protein in neonatal Group B streptococcal infection. Pediatr Infect Dis. 1985;4(2):145–148.
10. Altunhan H, Annagür A, Örs R, Mehmetoglu I. Procalcitonin measurement at 24 hours of age may be helpful in the prompt diagnosis of early-onset neonatal sepsis. Int J Infect Dis. 2011 Dec. 15(12):e854-458.