QuestionSBA
QuestionChoice
Streptococcus pneumoniae is a rare cause of early-onset neonatal sepsis, and is more common in late-onset neonatal sepsis (7-28 days old). In early-onset disease, pneumococci may be transmitted transplacentally, secondary to maternal bacteraemia, or transmitted from the mother transvaginally during delivery, although is not commonly present in vaginal flora and colonisation is rare. In late-onset neonatal sepsis it is more common as horizontal transmission from colonised visitors or health care workers has more time to occur
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Streptococcus pneumoniae
QuestionChoice
E. coli is the second most common pathogen for early-onset neonatal sepsis, accounting for approximately 24% of all episodes. The overall incidence of E. coli neonatal sepsis has remained stable after introduction of intrapartum antibiotic prophylaxis, but the incidence has increased in very low birth weight infants alongside worsening antibiotic-resistant patterns
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Escherichia coli
QuestionChoice
Staphylococcus aureus is a less common cause of early-onset neonatal sepsis than GBS and E. coli. It is more associated with late-onset neonatal sepsis (7-28 days old) where horizontal transmission from colonised visitors or health care workers is common
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Staphylococcus aureus
QuestionChoice
Listeria monocytogenes accounts for approximately 5% of early-onset neonatal sepsis in premature neonates, although it is rare in those >35 weeks gestation. It is commonly transmitted by aspiration or swallowing of amniotic fluid or vaginal secretions from the mother, although can also be transmitted transplacentally. Pregnant women typically acquire listeria infection from contaminated foods such as contaminated meats, poultry, dairy products, and vegetables
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Listeria monocytogenes
QuestionChoice
GBS is harboured asymptomatically in various sites, including the genital tract. Early-onset neonatal sepsis (<72 hours from birth) is most commonly caused by transmission of pathogens from the mother's genital tract during delivery. Risk factors for neonatal sepsis include prolonged prelabour rupture of membranes, intrapartum fever and suspected or confirmed bacterial infection. The most common pathogen in early-onset neonatal sepsis is GBS, causing 38-43% of all cases
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Group B streptococcus (GBS)
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I don’t get why the mother would have a temperature in labour? Since GBS is harmless for her? 
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Acute Ketone
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# Summary
 

Neonatal sepsis, a severe infection occurring in infants younger than 90 days of age, is classified into early onset (within 72 hours of life) and late-onset (after 72 hours). Key causes of early onset sepsis include Group B Streptococcus and other microbes ascending from the cervix, and pathogens like Listeria, Toxoplasma, Rubella, and CMV via the placenta. Late-onset sepsis is predominantly caused by Staphylococcus aureus, Staphylococcus epidermidis, E. coli, Pseudomonas, and Klebsiella. Risk factors comprise of premature birth, multiple pregnancies, prolonged rupture of membranes, and maternal intrapartum fever. Initial investigations include FBC, CRP, and blood culture, supplemented by lumbar puncture or chest X-ray based on symptoms. Management typically begins with empirical treatment using benzylpenicillin and gentamicin, followed by adjustments according to culture results and clinical progress.
 

# Definition
 
Neonatal sepsis is a severe systemic infection occurring in infants less than 90 days old, classified into early onset (within 72 hours of life) and late-onset (after 72 hours of life).

Early onset neonatal sepsis is often caused by ascending infections from the maternal genital tract or transplacental infections. Late-onset neonatal sepsis usually results from organisms present in the hospital environment or the infant's intestinal flora.
 

# Epidemiology
 
Around 2 in every 1,000 live births are affected by serious acute infections. The incidence rises to 26 per every 1,000 live births in infants weighing less than 1,000 grams. The majority of cases present in the first 24 hours of life. 

# Aetiology
 

Early onset neonatal sepsis (<72 hours of life) is commonly caused by:
 

 -  Ascending microorganisms from the cervix:
  
  - E. coli. and Group B streptococcus (GBS) (most common) 
  -  Typically colonises the genital tract
  -  Can cause asymptomatic bacteriuria or UTI in the mother
  -  There is no routine screening for GBS in the UK
  -  IV benzylpenicillin is the recommended treatment during childbirth if risk factors are present
  
 -  Transplacental infections:
  
  -  Listeria
  -  Toxoplasma
  -  Rubella
  -  CMV
 

Late-onset sepsis (>72 hours of life) is frequently caused by:
 

 -  Staphylococcus aureus (most common)
 -  Staphylococcus epidermidis
 -  E. coli
 -  Pseudomonas
 -  Klebsiella
 

The following risk factors significantly increase the likelihood of early-onset neonatal sepsis:
 

 -  Multiple pregnancies with a sibling who has suspected or confirmed infection
 -  Evidence of GBS in a previous baby or current pregnancy
 -  Premature birth
 -  Rupture of membranes >18 hours for pre-term babies, or >24 hours for term babies
 -  Maternal intrapartum temperature >38C
 -  Suspected or confirmed maternal sepsis
 -  Chorioamnionitis
 

# Signs and Symptoms
 

Clinical presentations of neonatal sepsis can vary:

- Nonspecific symptoms 
    - Feeding problems
    - Temperature instability
    - Reduced levels of consciousness 
- Respiratory distress
- Jaundice  
- Shock and multi-organ failure 
 
There may be signs specific to the site of infection:
 
 - Purulent discharge from the eyes may indicate infection with chlamydia or gonococcus
 - Periumbilical cellulitis 
 - Signs of meningitis: bulging fontanelle, seizures 
 

# Differential Diagnosis
 

The clinical picture of neonatal sepsis can mimic a variety of other conditions including:
 

 -  **Metabolic and endocrine disorders**: Presents with lethargy, poor feeding, and seizures. Hypoglycaemia, hypocalcaemia, and congenital adrenal hyperplasia are common examples.
 -  **Cardiovascular disorders**: Manifestations include cyanosis, pallor, and tachypnoea. Examples include congenital heart disease and persistent pulmonary hypertension of the newborn.
 -  **Respiratory disorders**: Conditions like transient tachypnoea of the newborn, neonatal pneumonia, and respiratory distress syndrome present with respiratory distress and cyanosis.
 -  **Neurological disorders**: Conditions like intraventricular haemorrhage and hypoxic-ischemic encephalopathy present with altered levels of consciousness, seizures, and abnormal tone.
 

# Investigations
 

The key investigations for diagnosing neonatal sepsis include:
 
 - Temperature is assessed in the axilla 
 -  Full blood count (FBC), C-reactive protein (CRP), and blood culture. A blood culture should be taken **before** the first dose of antibiotics
 -  Consider lumbar puncture (LP) in the presence of neurological symptoms or strong clinical suspicion. LP is essential if neonatal meningitis is suspected as neonates do not often have clear signs of meningitis. 
 -  Chest X-rays are advised only if there is a strong suspicion of a chest source. NICE advises against a urine culture in early-onset neonatal sepsis
 -  CRP should be repeated 24-36 hours after the initial dose of antibiotics
 -  If late-onset neonatal sepsis, a urine sample should be sent for microscopy and culture. 

If there are localising signs of infection (ie purulent discharge from the eye or umbilicus) then swabs can be sent for microbiology. 
 

# Management
 

For early-onset neonatal sepsis: 
 
 -  NICE recommends empirical treatment with IV benzylpenicillin and IV gentamicin 
  -  The treatment regimen is adjusted based on culture results and the clinical picture
  -  Monitoring of gentamicin levels is required due to its narrow therapeutic index and potential for toxicity
  -  Antibiotics are typically given for 7 days 

For late-onset neonatal sepsis:
 
 - NICE recommends narrow-spectrum antibiotics (IV flucloxacillin and IV gentamicin) 


Other special considerations:
 
 -  If concerned about bacterial meningitis, IV cefotaxime and IV gentamicin should be used 
 -  If necrotising enterocolitis is suspected, add metronidazole to cover for anaerobic bacteria 
 -  In a septic infant born to a febrile mother with chorioamnionitis, to cover for Listeria bacteria, IV amoxicillin and IV gentamicin will be used
 -  IV aciclovir may be used if there are signs of potential Herpes Simplex Virus (HSV) infection (i.e. thrombocytopaenia, hepatomegaly, encephalitis, vesicular rash)
 -  IV Ganciclovir may be used for suspected congenital cytomegalovirus (CMV) in infants with "blueberry muffin" purpuric rash, colitis, thrombocytopenia or hepatic dysfunction. 
 -  IV ambisome may be used if a fungal cause is suspected (i.e. thrombocytopenia, very low birth weight infants and infants not responding to broad-spectrum antibiotics) 

  
# Prevention 

The risk of neonatal sepsis is reduced by:

- Prophylactic antibiotics during labour for women who have evidence of GBS colonisation, are in pre-term labour or have chorioamnionitis. 

For early-onset neonatal sepsis, if the blood cultures in the neonate are positive, obstetrics should be notified to consider antibiotic treatment for the mother. 

# Complications

- Sepsis can cause multi-system organ failure and is potentially fatal.
- Seizures may occur.
- Chronic complications may include bronchopulmonary dysplasia, intraventricular haemorrhage and necrotising enterocolitis. 


# Prognosis

Neonatal sepsis has a 2-4% mortality rate in the UK. Early identification and treatment of neonatal sepsis offers the best prognosis. 
 

# NICE Guidelines
 
[NICE Guidelines: Neonatal infection: antibiotics for prevention and treatment](https://www.nice.org.uk/guidance/ng195/resources/neonatal-infection-antibiotics-for-prevention-and-treatment-pdf-66142083827653)

# References

[RCOG Green-top guideline: Group B streptococcal Disease, Early-onset](https://obgyn.onlinelibrary.wiley.com/doi/full/10.1111/1471-0528.14821) 

[NHSGGC Paediatrics for Health Professionals Early-onset sepsis in the neonate: prevention and treatment](https://www.clinicalguidelines.scot.nhs.uk/nhsggc-guidelines/nhsggc-guidelines/neonatology/early-onset-sepsis-in-the-neonate-prevention-and-treatment/)

[Patient Info Congenital, Perinatal and Neonatal Infections](https://patient.info/doctor/congenital-perinatal-and-neonatal-infections) 

[NHSGGC Paediatric for Health Professionals](https://www.clinicalguidelines.scot.nhs.uk/nhsggc-guidelines/nhsggc-guidelines/neonatology/antibiotic-guidelines-for-the-neonatal-unit/)
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Paediatrics
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Group B streptococcus is the most common cause of early-onset neonatal sepsis, particularly following prolonged rupture of membranes and maternal fever.
A woman brings her newborn boy to A&E with signs of respiratory distress. He was born 36 hours ago at 39 weeks and is currently grunting, tachypnoeic, and pyrexial with nasal flaring and use of accessory muscles. You suspect he has neonatal sepsis.

The mother had not attended any of her pre-natal screening sessions and reports her waters breaking over 24 hours before she went into labour. She also had a temperature in labour

Which of the following is the most likely organism responsible for this early-onset neonatal sepsis?
a