TABLE 1127 Signs and Symptoms of Neonatal Sepsis

The bacterial causes of neonatal sepsis tend to reflect the organisms that colonize the female genital tract and nasal mucosae of caregivers. In general, the two groups of pathogens most frequently encountered have been gram-positive cocci, such as b-hemolytic streptococci, and enteric organisms, such as E. coli and Klebsiella species, and H. influenzae. Listeria monocytogenes, a gram-positive rod, is a very common pathogen that causes sepsis and meningitis in neonates. Viral infections are also common and are most likely due to enteroviruses (coxsackievirus and echovirus) acquired at the time of delivery or RSV and influenza A virus acquired postnatally.

When a neonate is thought to be septic, microscopic analysis of cerebrospinal fluid, blood, and urine, and cerebrospinal cultures should be obtained. The infant should be admitted and intravenous antibiotics started. Initial treatment of a neonate with suspected bacterial septicemia or meningitis entails a combination of ampicillin and an aminoglycoside. An alternative regimen of ampicillin and a cephalosporin (e.g., cefotaxime or ceftazidime) is active against most etiologic gram-negative bacilli and can be used in cases when gram-negative meningitis is strongly suspected.

Febrile infants between 4 to 8 weeks of age who satisfy the following criteria are candidates for outpatient management:

• No focus of bacterial infection (middle ear, skin, soft tissue, bone, or joint) on physical examination

• Well appearing (alert, active, and with good muscle tone), well hydrated and tolerating oral fluids adequately, no respiratory distress (respiratory rate <60 breaths per minute, no grunting respiration or retractions)

• Cerebrospinal fluid total white blood cell count less than 10/pL, complete blood count total white blood cell count less than 15,000/pL, urinalysis white blood cell count less than 10 cells/hpf, and negative results for bacteriuria, leukocytes, esterase, and nitrite

• No pulmonary infiltrates on chest radiograph

• Reliable caretaker ensuring close outpatient follow-up.

The decision to administer empiric ceftriaxone pending culture results depends largely on the physician's level of comfort. We prefer to treat, since potentially serious complications, such as focal bacterial infection progressing to bacteremia and septicemia, and seeding of central nervous system can result from misdiagnosed ("occult") serious bacterial infection that is not treated promptly. Therefore, the therapeutic benefit of administrating ceftriaxone pending culture results outweighs both therapeutic risk and cost considerations. It should be emphasized that thorough and frequent reevaluations of these infants are essential to monitor changes in the clinical course and culture results.51,5,5,54,55and 56

Apparent Life-Threatening Events

An apparent life-threatening event (ALTE) (T§bJ§JJ.2:;8!) is an "episode that is frightening to the observer and is characterized by some combination of apnea (central or occasionally obstructive), color change (usually cyanotic or pallid but occasionally erythematous or plethoric), marked change in muscle tone (usually marked limpness), choking, or gagging. In some cases the observer fears that the infant has died."

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