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Sepsis in the Newborn

by Arthur E. Kopelman, MD

Sepsis is bacterial infection in the blood.

  • Newborns with sepsis are listless, do not feed well, and often have a low body temperature.

  • The diagnosis is based on symptoms and the presence of bacteria in the blood.

  • Most newborns who recover from sepsis do not have long-term problems.

  • Treatment involves antibiotics, fluids given by vein (intravenously), and sometimes a ventilator to support breathing and drugs to support blood pressure.

Premature infants are at much higher risk of both early-onset and late-onset sepsis than are infants born at full term because of their immature immune system. Premature newborns lack certain antibodies against specific bacteria because these antibodies do not cross the placenta from the mother into the fetus’s blood until late in pregnancy.

Other risk factors for and causes of sepsis differ depending on whether sepsis develops in the first few days of life (early-onset sepsis) or 7 days or more after birth (late-onset sepsis).

Early-Onset Sepsis

Risk factors include the following:

  • Premature prolonged rupture of the fluid-filled membranes that surround the fetus

  • Infection in the mother

  • Presence of group B streptococcus (GBS) in the mother

The risk of sepsis is greater if the fluid-filled membranes that surround the fetus rupture more than 18 hours before birth or if the mother has an infection (particularly of the urinary tract or lining of the uterus).

The most common types of bacteria causing sepsis in the newborn around the time of birth are Escherichia coli and GBS, which are usually acquired during passage through the birth canal. Sepsis caused by GBS was the leading cause of early-onset sepsis until about a decade ago when screening of all expectant mothers for GBS became a routine part of prenatal care. If screening reveals GBS, the mother is given antibiotics when she goes into labor. The newborn, if delivered vaginally, is immediately given antibiotics.

Late-Onset Sepsis

Important risk factors include the following:

  • Prolonged use of catheters in arteries, veins, or both

  • Use of a breathing tube inserted through the nose or mouth (endotracheal tube) and attached to a ventilator to help support breathing

  • Prolonged hospitalization

Sepsis that occurs later is more likely to be acquired from unwashed hands or the environment and may be caused by various organisms.

Some Infections of Newborns

Infection

Transmission

Symptoms

Treatment and Prevention

Conjunctivitis

The bacteria Chlamydia or Neisseria gonorrhoeae infect the fetus during delivery.

Chlamydia: Conjunctivitis usually begins 5 to 14 days after delivery but sometimes 6 weeks after.

Newborns have swollen eyelids and a watery discharge from the eyes that contains increasing amounts of pus.

Neisseria gonorrhoeae: Conjunctivitis usually begins 2 to 5 days after delivery.

Newborns have severe inflammation of the eyelids and discharge of pus from the eyes.

Without treatment, blindness may occur.

Chlamydia: Erythromycin is given as an eye ointment for prevention and by mouth for treatment.

Neisseria gonorrhoeae: An eye ointment containing polymyxin and bacitracin, erythromycin, or tetracycline is used for prevention, and the antibiotic ceftriaxone given by vein for treatment.

Cytomegalovirus infection

The virus is thought to cross the placenta from the mother during pregnancy or during delivery.

After birth, newborns may become infected if breast milk contains the virus or if they are given a contaminated blood transfusion.

Most newborns do not have symptoms.

About 10% of newborns infected at birth are premature and have a low birth weight, a small head, growth delay, jaundice, small bruises, inflammation of the lungs or eyes, and an enlarged liver and spleen.

Newborns infected after birth can have an enlarged liver and spleen, hepatitis, a low platelet count, a high number of white blood cells, or all of these symptoms.

Hearing loss, vision loss, and intellectual disability may occur.

The infection cannot be cured.

Ganciclovir may help relieve some symptoms.

Newborns should have repeated hearing evaluations during the first year.

Hepatitis B

The infection can occur during delivery if the mother is infected.

Chronic liver disease (such as chronic hepatitis or cirrhosis) develops but usually does not cause symptoms until young adulthood.

All newborns are given hepatitis B virus vaccine before hospital discharge.

A newborn born to an infected mother is given hepatitis B virus vaccine and hepatitis B immune globulin within 12 hours of birth.

Herpes

Usually, the virus (herpes simplex) is transmitted during delivery through the mother’s infected genital tract.

Usually, a rash of small fluid-filled blisters appears.

Infection may be widespread, affecting many organs, such as the eyes, lungs, liver, brain, and skin.

Other symptoms include sluggishness, diminished muscle tone, respiratory distress, pauses in breathing (apnea), and seizures.

The antiviral drug acyclovir is given by vein (intravenously).

Eye infections are treated with trifluridine drops and acyclovir given intravenously.

Human immunodeficiency virus (HIV) infection

The virus is transmitted from mother to fetus during pregnancy or to the newborn during labor and delivery or after birth through breastfeeding.

Symptoms range from none to very severe (AIDS).

The lymph nodes may swell.

Infection can affect many organs such as the liver, spleen, heart, kidneys, brain, and spinal cord.

Symptoms can also include recurrent diarrhea, poor weight gain, invasive bacterial infections, and viral infections.

Antiretroviral drugs are used, and consultation with a specialist and enrollment in a clinical trial are advised.

Early diagnosis and treatment of infections can help.

Human papillomavirus infection

Usually, newborns become infected during delivery.

Warts grow in the windpipe and can alter the newborn’s cry and sometimes cause difficulty breathing or even block the airways.

The lungs may become infected.

Warts are removed surgically.

The drug interferon can reduce the risk of recurrent infections.

Females aged 9 to 26 should be vaccinated.

Rubella

The virus may cross the placenta during pregnancy. Infection is now rare because vaccination is routine.

Infection is more severe if the fetus is infected early in pregnancy.

Effects on the fetus range from death before birth to birth defects or to hearing loss without other symptoms.

Newborns may have a low birth weight, brain inflammation, cataracts, damage to the retina, heart defects, an enlarged liver and spleen, bruising, bluish red spots, enlarged lymph nodes, and pneumonia.

No specific treatment is available.

Vaccinating all women of childbearing age before pregnancy can prevent the infection.

If an expectant mother who has not been immunized comes into close contact with an infected person early in pregnancy, she may be given an injection of immune globulin.

Syphilis

The bacteria ( Treponema pallidum) cross the placenta during pregnancy if the mother acquires syphilis during pregnancy or if she has been inadequately treated for syphilis in the past.

Stillbirth or premature birth may occur.

Newborns may have no symptoms.

During the first month of life, large blisters or a flat copper-colored rash may develop on palms and soles. Raised bumps may develop around the nose and in the diaper area. Newborns may not grow well. They may have cracks around the mouth, or mucus, pus, or blood may run from the nose.

Usually, the lymph nodes, liver, and spleen are enlarged.

Rarely, inflammation of the eye or brain, seizures, meningitis, or intellectual disability occurs, but these symptoms may not appear until the child is age 2 years or older.

Before birth, the mother is treated with penicillin.

After birth, the mother, if still infected, and newborn are treated with penicillin.

Toxoplasmosis

The parasite ( Toxoplasma gondii) may cross the placenta from the mother to the fetus during pregnancy.

Infection is more severe if the fetus is infected early in pregnancy.

The fetus may grow slowly and be born prematurely.

Newborns may have a small head, brain inflammation, jaundice, an enlarged liver and spleen, and inflammation of the heart, lungs, or eyes.

Rashes may occur.

Avoiding handling cat litter during pregnancy is recommended.

Transmission from the mother to the fetus may be prevented if the mother takes spiramycin.

Pyrimethamine and sulfonamides may be taken later in pregnancy if the fetus is infected.

Infected newborns with symptoms are treated with pyrimethamine, sulfadiazine, and leucovorin.

Inflammation of the heart, lungs, or eyes is treated with corticosteroids.

Symptoms and Diagnosis

Newborns with sepsis are usually listless, do not feed well, and often have a low body temperature. Other symptoms may include pauses in breathing (apnea), fever, pale color, and poor skin circulation, with cool extremities, abdominal swelling, vomiting, diarrhea, seizures, jitteriness, and jaundice. The diagnosis is suggested by the newborn’s symptoms and the results of a complete blood count. A definite diagnosis is made only if bacteria are identified in a culture of the newborn’s blood.

One of the most serious complications of sepsis is infection of the membranes surrounding the brain (meningitis). Newborns with meningitis may have extreme sluggishness (lethargy), coma, seizures, or bulging of the soft spot between the skull bones (fontanelle). Doctors can diagnose meningitis by doing a spinal tap (lumbar puncture), examining the cerebrospinal fluid, and culturing a sample of this fluid.

Prognosis and Treatment

Sepsis is the major cause of death in premature newborns after the first week. Newborns who recover from sepsis should not have long-term problems, except those with meningitis, who may have developmental delay, cerebral palsy, seizures, or hearing loss.

While awaiting blood culture results, doctors give intravenous antibiotics to newborns with suspected sepsis. Once the specific organism has been identified, the type of antibiotic can be adjusted. In addition to antibiotic therapy, other treatments may be needed, such as use of a ventilator, intravenous fluids, and support of blood pressure and circulation.

Resources In This Article

Drugs Mentioned In This Article

  • Generic Name
    Select Brand Names
  • ACHROMYCIN V
  • ZOVIRAX
  • VIROPTIC
  • No US brand name
  • ERY-TAB, ERYTHROCIN
  • ROCEPHIN
  • CYTOVENE
  • DARAPRIM
  • BACIIM