• Risk Factors:
◦ Red Flag: Suspected or confirmed infection in another baby in a multiple pregnancy.
◦ Other Factors: Invasive Group B streptococcal (GBS) infection in a previous baby, maternal GBS colonization/infection in the current pregnancy, preterm birth (<37 weeks) following spontaneous labor, and confirmed rupture of membranes for >18 hours (preterm) or >24 hours (term).
• Clinical Indicators:
◦ Red Flags: Apnea, seizures, signs of shock, need for cardiopulmonary resuscitation, or need for mechanical ventilation.
◦ Other Indicators: Altered behavior (floppiness), feeding difficulties (intolerance, refusal, abdominal distension), jaundice within 24 hours of life, respiratory distress (grunting, tachypnea), and temperature instability (<36°C or >38°C).
• Management Actions:
◦ Antibiotics should be started if any red flag is present, or if there are two or more non-red-flag risk factors or clinical indicators.
◦ If only one non-red-flag risk factor or clinical indicator is present, clinicians may use judgement to withhold antibiotics and monitor the baby's vital signs for at least 12 hours from birth.
• Investigations and Empirical Treatment:
◦ Perform a blood culture, send CBC, and measure C-reactive protein (CRP) before starting treatment.
◦ First-line antibiotics are ampicillin and amikacin.
If ampicillin is not available, add co-amoxiclav and amikacin, or cefotaxime and amikacin.
(For drug doses, refer to the latest edition of Harriet Lane)
◦ The "Golden Hour": Antibiotics must be administered as soon as possible and always within one hour of the decision to treat.
• Monitoring and Stopping Treatment:
◦ Re-measure CRP 18–24 hours after presentation.
◦ Review at 36 hours: Stop antibiotics if blood cultures are negative, leukocyte count and platelet counts are normal, the baby is clinically well, and CRP levels are <15 mg/L.
II. Late-Onset Neonatal Infection (>72 Hours)
• Clinical Presentation: Signs can be vague, including mottled or ashen appearance, bulging fontanelle, petechiae, reduced bowel sounds, and "parent or care-giver concern" regarding behavior changes, seizures, reluctance to feed, breathing difficulty, respiratory distress, jaundice, hypothermia, or lethargy.
• Investigations:
◦ Blood Culture: Obtain from a peripheral vein using a closed, non-touch aseptic technique.
◦ CRP: Measure at presentation and again 18–24 hours later, as there is often a delay in serum CRP rising after symptom onset.
. CBC
◦ Lumbar Puncture (LP): Perform if there is a strong clinical suspicion of infection or signs suggested of meningitis.
• Treatment:
◦ First-line empirical treatment is typically a combination of co-amoxiclav and amikacin (non CNS infection, as co-amoxiclav and amikacin do not cross blood brain barrier)
... If CNS infection is considered, start with ampicillin and cefotaxime in meningitic doses.
... Add metronidazole if NEC is suspected. (If Tazobactam-piperacillim or meropenem are being given and the diagnosis of NEC is considered, do not add metronidazole as per NHS guidelines)
◦ Antifungal Prophylaxis (after approval from consultant): Give prophylactic oral nystatin to babies ≤1500g or <30 weeks' gestation who are receiving antibiotics.
...Once cultures are available, switch to targetted antibiotic therapy reported in the blood culture.
... 2nd line antibiotics: Linezolid and Tazobactam-piperacillin
...3rd line antibiotics: Vancomycin and meropenem
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