Neonatal sepsis is caused by infection within the first 28 days of life. Early onset neonatal sepsis occurs within 72 hours of birth. It features high morbidity and mortality for the affected infant, particularly if treatment is delayed. Signs are non-specific, and a high degree of suspicion and a low threshold for starting treatment is required. Refer to policies and guidelines and involve seniors when treating patients.
Organisms
The most common organisms associated with neonatal sepsis include:
- Group B streptococcus (GBS) – transmitted from the mother’s vagina
- Escherichia coli (E. coli)
- Listeria – often associated with contaminated food (e.g., unpasteurised dairy)
- Klebsiella – often associated with hospital environments (e.g., neonatal ICU)
- Staphylococcus aureus – often associated with hospital environments (e.g., neonatal ICU)
TOM TIP: Remember group B strep (GBS) for your exams. This is a common bacteria living harmlessly in the vagina. It can be transferred to the baby during labour and cause neonatal sepsis. Prophylactic antibiotics during labour are used to reduce the risk of transfer if the mother is found to have GBS in their vagina during pregnancy.
Risk Factors
- Vaginal GBS colonisation
- GBS sepsis in a previous baby
- Maternal sepsis, chorioamnionitis or fever above 38ºC
- Prematurity (less than 37 weeks)
- Prelabour rupture of membrane
- Prolonged rupture of membranes
Clinical Features
The presenting features are typically non-specific:
- Temperature below 36°C or above 38°C
- Reduced tone and activity
- Poor feeding
- Respiratory distress
- Apnoea (temporary pause in breathing)
- Vomiting
- Tachycardia or bradycardia
- Hypoxia
- Jaundice within 24 hours
- Seizures
- Hypoglycaemia
- Abnormal bleeding
Red Flags
- Signs of shock
- Seizures
- Apnoea
- Requiring mechanical ventilation or CPR
- Presumed sepsis in another baby in a multiple pregnancy (e.g., twin)
Treating For Presumed Sepsis
Always check your local policy and consult with experienced paediatricians when treating neonates who potentially have sepsis. Most local policies will follow something similar to the NICE guidelines. A basic overview is:
- Monitor closely for at least 12 hours when there is one risk factor or clinical feature
- Start treatment when there are two or more risk factors or clinical features
- Start treatment if there is a single red flag
- Antibiotics should be given within 1 hour of deciding to start them
- Blood cultures and a baseline CRP should be taken before antibiotics are given
- Lumbar puncture is performed if infection is strongly suspected or there are features of meningitis (e.g. seizures)
Antibiotic Choice
The NICE guidelines (2024) recommend intravenous benzylpenicillin with gentamicin first-line. Always check local policies, as these will vary depending on regional data.
Ongoing Management
In well newborns being treated based on risk factors, the decision to stop antibiotics may be made 36 hours after starting treatment if:
- There was initially a weak suspicion of infection
- Blood culture is negative
- A second CRP (taken at 18-24 hours) is reassuring (e.g., within normal range and not trending upwards)
Antibiotics are usually continued for at least 7 days when there are positive blood cultures or a stronger suspicion of infection.
Last updated May 2025
Now, head over to members.zerotofinals.com and test your knowledge of this content. Testing yourself helps identify what you missed and strengthens your understanding and retention.
