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

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) 

• 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

• 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 

• 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 

• 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 1 hr after starting gentamicin infusion 
• If peak <8 mg/L, increase dose

• 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