Review Question - QID 217708

This baby presents with symptoms of poor feeding, lethargy, jaundice, and increased intracranial pressure in the setting of being febrile, which is overall concerning for neonatal sepsis and requires prompt antibiotic initiation.

Neonatal sepsis may be categorized as early-onset (day of life 0-3) or late-onset (day of life 4 or later). Early-onset sepsis is associated with the acquisition of microorganisms from the mother. Infection can occur via hematogenous, transplacental spread from an infected mother or, more commonly, via ascending infection from the cervix. Alternatively, late-onset sepsis usually occurs via the transmission of pathogens from the surrounding environment after delivery, such as contact from healthcare workers or caregivers. Empiric treatment with antibiotics should be started as soon as sepsis is clinically suspected, even without confirmatory lab data. Typical treatment regimens include intravenous ampicillin and aminoglycosides to cover for the most common pathogens in early-onset sepsis (Group B Streptococcus, E. coli, and L. monocytogenes). In late-onset sepsis, nosocomial coverage should be provided for hospital-acquired pathogens (e.g. coagulase-negative Staphylococcus, S. aureus, Pseudomonas species). In this vein, vancomycin and an aminoglycoside can be used. For CNS penetration, a third-generation cephalosporin should be considered.

Singh et al. outline the differentiation between early-onset and late-onset neonatal sepsis, the steps to clinical identification of these pathologies, and the appropriate steps in management.

Figure/Illustration A depicts a child with a slightly jaundiced appearance along with bulging fontanelles, signifying increased intracranial pressures.

Incorrect Answers:
Answer 2: Intubation is a necessary step in the case of severe lethargy begetting concern for airway protection or marked respiratory distress, which is not present in this patient.

Answer 3: Lumbar puncture should not be performed before imaging concludes that there is no risk for herniation and should not delay administration of antibiotics.

Answer 4: Magnetic resonance imaging of the head, which limits radiation exposure, is not a suitable first step in an acute circumstance with a septic patient as ultrasound may be a more timely imaging tool.

Answer 5: Ultrasound of the head may be used to rule out a mass that may put the baby at risk of herniation when a lumbar puncture is performed, but this is not the best first step as it may delay the administration of antibiotics in this acutely ill patient.

Bullet summary:
The best initial step in the management of a septic pediatric patient is obtaining blood cultures (with or without lumbar puncture) and prompt initiation of broad-spectrum antibiotics.