Neonatal sepsis: recognition, diagnosis, treatment and supportive care

Learning objectives

• Differentiate early- and late-onset sepsis and identify maternal, neonatal and healthcare risks.
• Recognise subtle and advanced clinical signs, including meningitis and septic shock.
• Obtain appropriate cultures and interpret tests without delaying antibiotics.
• Start empiric antimicrobial therapy according to current local guidance, then narrow or stop safely.
• Provide thermoregulation, respiratory, circulatory, glucose, nutritional and family-centred supportive care.
• Plan monitoring, duration, discharge, prevention and follow-up.

Definitions and timing

Definitions differ between surveillance systems; document the exact age and local definition. A newborn can have meningitis, urinary infection, pneumonia or omphalitis with or without positive blood culture.

Pathogens and risk factors

Likely organisms vary by setting and resistance pattern. Group B streptococcus, enteric gram-negative bacilli such as Escherichia coli, Klebsiella and other Enterobacterales, Staphylococcus aureus, coagulase-negative staphylococci, enterococci, and occasionally Listeria or fungi may occur. Obtain local antibiograms and follow Uganda guidance rather than assuming a textbook pattern.

• Prematurity, low birth weight, male sex and perinatal asphyxia.
• Maternal fever, suspected chorioamnionitis, untreated UTI, GBS risk, foul liquor or prolonged rupture of membranes.
• Unclean delivery, invasive procedures, umbilical/central catheters, ventilation, surgery and prolonged hospitalisation.
• Skin breakdown, parenteral nutrition, overcrowding, inadequate hand hygiene and antibiotic exposure.

Clinical presentation

Subtle early signs

Poor or absent feeding, weak suck, vomiting, temperature instability, reduced activity, irritability, abnormal cry, pallor, mottling, jaundice, hypoglycaemia, abdominal distension, reduced urine and apnoea may be the only clues. Do not wait for fever: neonates may be hypothermic or normothermic.

Respiratory and cardiovascular signs

Tachypnoea, grunting, nasal flaring, indrawing, cyanosis, recurrent apnoea, oxygen requirement, bradycardia, tachycardia, prolonged capillary refill, weak pulses, hypotension, cold extremities and oliguria indicate severe illness or shock.

Neurological signs

Lethargy, altered consciousness, hypotonia, abnormal tone, bulging fontanelle, high-pitched cry, seizures, irritability, poor suck or temperature instability raise concern for meningitis or encephalopathy.

Focal infection

Umbilical redness/pus, skin pustules, cellulitis, conjunctivitis, pneumonia, abdominal tenderness/distension, necrotising enterocolitis, osteomyelitis or septic arthritis can accompany bacteraemia.

Initial assessment: ABCDE

1. Airway: position, clear only visible obstruction, assess cry and protect airway.
2. Breathing: respiratory rate/effort, saturation, blood gas when available; provide oxygen/CPAP/ventilation as indicated.
3. Circulation: heart rate, pulses, capillary refill, blood pressure, temperature, urine output and lactate/perfusion.
4. Disability: consciousness, tone, seizures and bedside glucose; treat hypoglycaemia immediately.
5. Exposure: inspect cord/skin, assess abdomen, hydration, jaundice, weight and gestation while preventing heat loss.

Investigations

• Blood culture: obtain adequate volume before antibiotics when this does not delay treatment; document site and time.
• Full blood count: anaemia, platelet count and leukocyte pattern may support severity but cannot rule sepsis in or out alone.
• CRP/procalcitonin: trends can support stopping or continuing therapy, but timing and local assay matter; do not delay treatment for them.
• Blood gas/lactate, glucose, electrolytes, renal/liver function: assess shock, metabolic complications and drug safety.
• Lumbar puncture: perform when safe in suspected meningitis, bacteraemia without focus, seizures or neurological signs; stabilise airway/breathing/circulation first. Send CSF cell count, glucose, protein, Gram stain, culture and PCR where available.
• Urine culture: obtain by catheterisation or suprapubic aspiration in late-onset/community infection where indicated; bag urine is unreliable for culture.
• Chest radiograph/ultrasound: targeted to respiratory disease, line position, focal infection, abdominal signs or NEC.

Serial clinical examination is essential. A negative culture does not exclude sepsis after prior antibiotics or with low-volume sampling; a contaminant must be distinguished from true bacteraemia using clinical context and repeat cultures.

Empiric antimicrobial treatment

Supportive care

• Thermoregulation: incubator/radiant warmer or skin-to-skin when stable; treat hypothermia and fever while investigating causes.
• Respiratory: oxygen titrated to target, CPAP or ventilation for failure; monitor for apnoea, PPHN and pneumothorax.
• Circulation: cautious isotonic fluid bolus only when indicated, reassess frequently, and use inotropes for persistent shock under specialist care.
• Glucose/electrolytes: check repeatedly, correct hypoglycaemia, calcium and sodium abnormalities, and avoid fluid overload.
• Nutrition: continue expressed breast milk when safe; withhold/modify feeds in shock, ileus or NEC risk, using tube or parenteral nutrition appropriately.
• Renal: strict input/output, daily weight, creatinine and urine monitoring; modify nephrotoxic drugs.
• Pain and developmental care: minimise procedures, support sleep, protect skin and involve parents.

Specific complications

• Septic shock: oxygen, vascular access, glucose, cautious fluids, antibiotics and vasoactive support; seek senior help early.
• Meningitis: seizure management, CSF culture/PCR, adequate CNS-penetrating antibiotics and hearing/developmental follow-up.
• NEC: stop feeds, gastric decompression, broad antibiotics, serial abdominal examinations/imaging and surgical review.
• Infected central line: culture line and peripheral blood, assess removal/replacement and treat according to organism.
• Disseminated fungal disease: suspect in very preterm infants with prolonged antibiotics/TPN and persistent sepsis; obtain specialist advice.

Monitoring and treatment duration

Record observations frequently: temperature, heart rate, breathing, saturation, perfusion, blood pressure, glucose, urine, feeding, abdominal findings and neurological status. Repeat cultures for persistent bacteraemia. Duration depends on confirmed focus, organism, meningitis, response and local guideline; uncomplicated culture-negative illness may be stopped early after reassuring serial assessment, whereas meningitis, bone/joint infection, endocarditis and NEC require prolonged specialist-directed courses.

Prevention

• Antenatal screening/treatment, clean birth, hand hygiene, breastfeeding and early skin-to-skin.
• Strict asepsis for lines, ventilation and procedures; remove invasive devices promptly.
• Antibiotic stewardship and local resistance surveillance.
• Teach families newborn danger signs and ensure early postnatal review.
• Audit every neonatal death or sepsis cluster for preventable delays and infection-control failures.

Discharge and follow-up

Discharge only when temperature, breathing, perfusion and feeding are stable; cultures/results are reviewed; medicines and duration are clear; caregivers demonstrate feeding and danger-sign recognition; and follow-up is arranged. Infants recovering from meningitis, shock, prolonged ventilation or severe sepsis need hearing, vision, growth and neurodevelopmental surveillance.

OSCE and exam pearls

• Neonatal sepsis may present with poor feeding or hypothermia rather than fever.
• Take blood culture before antibiotics when feasible, but never delay life-saving treatment.
• Apnoea, shock, seizures and abdominal distension are sepsis until dangerous alternatives are excluded.
• Review antibiotics at 36–48 hours using cultures and serial clinical assessment.
• Supportive care—warmth, oxygen, glucose, fluids, nutrition and monitoring—is as important as antibiotics.

References

• SlideShare: Neonatal sepsis.
• WHO recommendations for serious bacterial infections in infants aged 0–59 days.
• WHO newborn infections guidance.
• Current Uganda neonatal and antimicrobial-treatment protocols.

Safety note: Antibiotic doses, resistance patterns, treatment duration and referral criteria must be checked against the current Uganda guideline and neonatal-unit protocol.