DO NOT USE FOR CLINICAL PRACTICE
Please use current guidelines available on the UHNM intranet for patient treatment
Please use current guidelines available on the UHNM intranet for patient treatment
Based on NICE CG149 Antibiotics for early onset neonatal infection
Updated December 2016, NICE Early onset neonatal infection pathway updated March 2019 and NICE NG195 Neonatal infection: antibiotics for prevention and treatment April 2021
RISK FACTORS FOR INFECTION
Red flag risk factor
- Suspected or confirmed infection in another baby in the case of a multiple pregnancy
Other risk factors
- Invasive Group B streptococcal infection in a previous baby
- Maternal Group B streptococcal colonisation, bacteriuria or infection in the current pregnancy
- Preterm birth (<37 weeks) following spontaneous labour
- Confirmed rupture of membranes for >18 hr before a preterm birth
- Confirmed pre-labour rupture of membranes at term for >24 hr before onset of labour
- Intrapartum fever >38°C if there is confirmed or suspected bacterial infection
- Clinical diagnosis of chorioamnionitis
CLINICAL INDICATORS SUGGESTIVE OF INFECTION
Red flag clinical indicators
- Apnoea
- Need for cardiopulmonary resuscitation
- Seizures
- Need for mechanical ventilation
- Signs of shock
Other clinical indicators
- Altered behaviour or responsiveness
- Altered muscle tone (e.g. floppiness)
- Feeding difficulties (e.g. feed refusal)
- Feed intolerance including abdominal distension, vomiting, excessive gastric aspirates
- Abnormal heart rate (bradycardia or tachycardia)
- Signs of respiratory distress (including grunting, recession, tachypnoea)
- Hypoxia (e.g. central cyanosis or reduced oxygen level)
- Jaundice in first 24 hr of life
- Signs of neonatal encephalopathy
- PPHN
- Temperature <36°C or >38°C, not explained by environmental factors
- Unexplained excessive bleeding, thrombocytopenia or abnormal coagulation
- Hypo/hyperglycaemia
- Metabolic acidosis (BE ≥10)
Red flag signs and clinical indicators suggestive of neonatal infection
- Suspected or confirmed infection in another baby in the case of a multiple pregnancy
- Apnoea
- Seizures
- Need for cardiopulmonary resuscitation
- Signs of shock
- Need for mechanical ventilation
ACTIONS
- Any red flags or no red flags but ≥2 risk factors or clinical indicators
- perform investigations, including blood cultures, and start antibiotics
- No red flag or clinical indicators but 1 risk factor, or no red flag or risk factors but 1 clinical indicator
- use clinical judgement and consider withholding antibiotics
- monitor baby for clinical indicators of possible infection, including vital signs
- monitor for at least 12 hr from birth (at 1 hr, 2 hr and then 2-hrly for 10 hr)
- If further clinical concerns, perform investigations including blood cultures and start antibiotics
- Whenever decision made to give antibiotics, start as soon as possible and always within 1 hr of decision
KAISER PERMANENTE SEPSIS RISK CALCULATOR (KP-SRC)
- Online tool used to determine whether a baby is at risk of early onset neonatal infection and whether antibiotic treatment is indicated. NICE has endorsed this as an alternative to the framework above for babies born at ≥34 weeks provided that it is used as part of a prospective audit
- In this guideline the KP-SRC is applied to well babies who meet the NICE criteria for treatment with antibiotics for possible early onset neonatal infection to determine whether they should receive antibiotics
- If baby meets the criteria for antibiotic treatment refer to the Kaiser Permanente sepsis risk calculator guideline and apply KP-SRC online tool
- If KP-SRC recommends withholding antibiotics continue to follow the Kaiser Permanente sepsis risk calculator guideline
- Continue with this guideline, following the advice below if:
- KP-SRC recommends antibiotic treatment or
- baby does not meet the KP-SRC inclusion criteria or
- online tool is not available or
- local trust has chosen not to adopt KP-SRC
INVESTIGATIONS BEFORE STARTING ANTIBIOTICS
- Blood culture (in all)
- Measure CRP at presentation and 18–24 hr after
- If strong clinical suspicion of infection or signs of meningitis, perform lumbar puncture (LP), if thought safe to do
- if performing LP will delay antibiotics, give antibiotics first
- Do not carry out routine urine MC&S
- Take skin swabs only if clinical signs of localised infection
- If purulent eye discharge (may indicate serious infection e.g. chlamydia or gonococcus):
- collect eye swabs for urgent MC&S and swabs in viral transport media for viral PCR, especially if looking for chlamydia or gonococcus (see Conjunctivitis guideline)
- start systemic antibiotics while awaiting results
- If signs of umbilical infection, including purulent discharge or periumbilical cellulitis, perform blood culture, take swab for MC&S and start flucloxacillin and gentamicin IV
- if microbiology results indicate infection not due to Gram-negative infection stop gentamicin
Choice of IV antibiotics
- Use benzylpenicillin and gentamicin as first choice for empirical treatment
- If microbiological evidence of Gram-negative bacterial sepsis, add a third antibiotic that is active against Gram-negative bacteria e.g. cefotaxime. If Gram-negative infection subsequently confirmed, stop benzylpenicillin
Benzylpenicillin
- 25 mg/kg 12-hrly
- If baby appears very ill, give 25 mg/kg 8-hrly
Gentamicin
- Follow local guideline or:
- 5 mg/kg
- if a second dose to be given (see below), give 36 hr after first dose
- interval may be shortened based on clinical judgement e.g. for Gram-negative infection or if baby appears very ill
- Monitoring of gentamicin – see below
INVESTIGATIONS DURING ANTIBIOTIC TREATMENT
- CRP: measure before starting antibiotics and 18–24 hr after presentation
- Consider LP if:
- positive blood culture (other than CoNS) or
- baby does not respond satisfactorily to antibiotics or
- there is a strong clinical suspicion of infection or
- there are clinical symptoms or signs suggestive on meningitis
- Asymptomatic babies on postnatal ward/transitional care unit with CRP ≤60 do not require routine LP, but should be reviewed by middle grade doctor
Review treatment at 36 hr
- Stop antibiotics if:
- initial clinical suspicion of infection was not strong and
- negative blood culture and
- baby is well with no clinical indicators of possible infection and
- levels and trends of CRP are reassuring i.e. CRP <15 mg/L on both tests
Usual duration of treatment
- If blood culture negative and baby is well with no strong clinical suspicion of infection and neither CRP >60, antibiotics can be stopped after 5 days
- If blood culture positive or strong clinical suspicion of infection or either CRP >60, treat for 7 days
- Continue treatment beyond 7 days if:
- baby is not fully recovered or
- this is advisable based on blood culture result and expert microbiological advice if necessary
- If any doubt about duration of treatment, discuss with consultant
Meningitis
- If meningitis suspected but Gram stain is uninformative, use amoxicillin and cefotaxime
- Review treatment decisions taking CSF results into account
- If CSF Gram stain suggests GBS, give benzylpenicillin 50 mg/kg 12-hrly and gentamicin 5 mg/kg every 36 hr
- If CSF culture confirms GBS, continue benzylpenicillin for ≥14 days and gentamicin for 5 days
- If CSF culture or Gram stain confirms Gram-negative infection, stop amoxicillin and treat with cefotaxime alone
- If blood culture or CSF culture positive for listeria, consider stopping cefotaxime and treating with amoxicillin and gentamicin
- If CSF Gram stain or culture suggests any organism other than GBS, use an antibiotic regimen based on local expert microbiological advice
Therapeutic monitoring of gentamicin
- Follow local guidelines or:
- Trough concentrations:
- if second dose to be given, measure before administering
- review level before giving third dose
- monitor before every third dose, or more frequently if necessary (e.g. concern about previous level or renal impairment)
- adjust dose interval aiming to achieve level of <2 mg/L
- if course lasts >3 doses, level of <1 mg/L is advisable
- if a trough level is not available, do not withhold next dose of gentamicin unless there is evidence of renal dysfunction (raised serum urea, creatinine or anuria)
- Peak concentrations:
- measure in selected babies e.g.:
- with oedema
- with macrosomia (birth weight >4.5 kg)
- unsatisfactory response to treatment
- proven Gram-negative infection
- measure in selected babies e.g.:
- Measure 1 hr after starting gentamicin infusion
- If peak <8 mg/L, increase dose
DISCHARGE FOLLOWING GROUP B STREPTOCOCCAL INFECTION
- Advise mother that if she becomes pregnant again:
- increased risk of early onset neonatal infection
- to inform her maternity team that a previous baby had GBS infection
- intrapartum antibiotics will be recommended
- Inform mother’s GP in writing risk of:
- recurrence of GBS infection in this baby
- GBS infection in subsequent pregnancies
- If mother had GBS colonisation in this pregnancy but no infection in baby, this will not affect management of any further births