Identifying newborn at increased risk of sepsis and deciding which ones to evaluate further is not easy. It is true that the risk of sepsis is greater for infants with multiple risk factors or clinical signs than for those with only a single indicator of possible infection; however, there is no simple way to estimate the magnitude of the risk implied by any particular combination of historical findings or clinical signs. We suggest the guidelines below.
Evaluating for Sepsis Risk
In the following situations, the infant should have a complete diagnostic evaluation and empiric antibiotic therapy:
- history of a prior infant with GBS sepsis
- preterm premature rupture of membranes
- maternal clinical chorioamnionitis
- infants in a multiple birth group if one is diagnosed with GBS sepsis
In all other situations, you must perform a risk assessment.
- The following is one way to assess common risk factors, based on odds ratios (O.R.) for developing neonatal sepsis when a single factor is present.
- These recommendations are only a guide, and are not meant to be a substitute for a physical examination or sound clinical judgment.
- Any newborn infant with clinical signs of sepsis should be considered for admission for full sepsis evaluation.
- CRP has good positive predictive value only at levels >5 mg/L and good negative predictive value if tested serially and level is <1 mg/L each time.
Risk Factors for Sepsis
Management RecommendationsLow Risk Criteria for Sepsis (OR <3.0)
Cyanosis
Tachypnea
Hypotonia
Hyperreflxia
Mec stained fluid
Preterm onset labor
Grunting
Hyperbilirubinemia >24h
Seizures
Retractions
Lethargy
Poor feeding
Moderate Risk Criteria for Sepsis (OR >3.0 but <6.0)
Diarrhea
Apgar <6 @ 5 minutes
Apnea
Splenomegaly
Maternal fever >37.5 C
Rash
Distended Abdomen
Hypertension
Hypotension
Bulging Fontanel
EGA 34-36 weeks
High Risk Criteria for Sepsis (OR >6)
Pustules
Bleeding
PROM >18 hours
Decreased perfusion
Tachycardia
Arrhythmia
Vasomotor instability
Hyperbilirubinemia <24h
Pallor
Fetal tachycardia in the 10 minutes prior to delivery
Persistent neonatal tachycardia
Cord blood pH <7.18
Twin with sepsis
Any 1 Low/Moderate Risk:
Evaluate/manage clinically and continue close observation. If develops increased or new signs, sepsis screen (CBC/diff, 2 CRPs: first >8hrs of life, second >24hrs after the first). If all reassuring, continue close observation, otherwise proceed to full sepsis evaluation. If develops additional increased or new signs, admit for full sepsis evaluation.
Any 2 Low/Moderate Risk , or
Any 1 High Risk, or
Any 1 High Risk plus 1 additional Low Risk:
Evaluate/manage clinically and perform sepsis screen (CBC/diff, 2 CRPs: first >8hrs of life, second >24hrs after the first). If all reassuring, continue close observation, otherwise proceed to full evaluation and treatment. If develops increased or new signs, admit for full sepsis evaluation.
Any 3 Low/Moderate Risk, or
Any 1 High Risk plus 1 Moderate Risk, or
Any 1 High Risk plus 2 Low Risk, or
Any 2 High Risk:
Admit for full sepsis evaluation.
ABurgos, WBenitz, reviewed 5-06
