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South Australian Paediatric Clinical Practice Guidelines
Neonatal Sepsis Presenting
from the community
Department for Health and Wellbeing, Government of South Australia. All rights reserved.
I INFORMAL COPY WHEN PRINTED Page 1 of 11
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Note:
This guideline provides advice of a general nature. This statewide guideline has been prepared to promote and
facilitate standardisation and consistency of practice, using a multidisciplinary approach. The guideline is based
on a review of published evidence and expert opinion.
Information in this statewide guideline is current at the time of publication.
SA Health does not accept responsibility for the quality or accuracy of material on websites linked from this site
and does not sponsor, approve or endorse materials on such links.
Health practitioners in the South Australian public health sector are expected to review specific details of each
patient and professionally assess the applicability of the relevant guideline to that clinical situation.
If for good clinical reasons, a decision is made to depart from the guideline, the responsible clinician must
document in the patient s medical record, the decision made, by whom, and detailed reasons for the departure
from the guideline.
This statewide guideline does not address all the elements of clinical practice and assumes that the individual
clinicians are responsible for discussing care with consumers in an environment that is culturally appropriate and
which enables respectful confidential discussion. This includes:
The use of interpreter services where necessary,
Advising consumers of their choice and ensuring informed consent is obtained,
Providing care within scope of practice, meeting all legislative requirements and maintaining
standards of professional conduct, and
Documenting all care in accordance with mandatory and local requirements
Explanation of the aboriginal artwork:
The aboriginal artwork used symbolises the connection to country and the circle shape shows the strong relationships amongst families and the aboriginal culture.
The horse shoe shape design shown in front of the generic statement symbolises a woman and those enclosing a smaller horse shoe shape depicts a pregnant
woman. The smaller horse shoe shape in this instance represents the unborn child. The artwork shown before the specific statements within the document
symbolises a footprint and demonstrates the need to move forward together in unison.
The term Aboriginal is used to refer to people who identify as Aboriginal, Torres Strait Islanders, or both Aboriginal and Torres Strait
Islander. This is done because the people indigenous to South Australia are Aboriginal and we respect that many Aboriginal people prefer the
term Aboriginal . We also acknowledge and respect that many Aboriginal South Australians prefer to be known by their specific language
group(s).
Cultural safety enhances clinical safety.
To secure the best health outcomes, clinicians must provide a culturally safe health
care experience for Aboriginal children, young people and their families. Aboriginal
children are born into strong kinship structures where roles and responsibilities are
integral and woven into the social fabric of Aboriginal societies.
Australian Aboriginal culture is the oldest living culture in the world, yet Aboriginal
people currently experience the poorest health outcomes when compared to non-
Aboriginal Australians.
It remains a national disgrace that Australia has one of the highest youth suicide rates
in the world. The over representation of Aboriginal children and young people in out of
home care and juvenile detention and justice system is intolerable.
The accumulative effects of forced removal of Aboriginal children, poverty, exposure to
violence, historical and transgenerational trauma, the ongoing effects of past and
present systemic racism, culturally unsafe and discriminatory health services are all
major contributors to the disparities in Aboriginal health outcomes.
Clinicians can secure positive long term health and wellbeing outcomes by making well
informed clinical decisions based on cultural considerations.
Neonatal Sepsis
Presenting from the Community
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Purpose and Scope of PCPG
The Management of Neonatal Sepsis Presenting from the Community Clinical Guideline is
primarily aimed at medical staff working in any of primary care, local, regional, general or
tertiary hospitals. It may however assist the care provided by other clinicians such as nurses.
The information is current at the time of publication and provides a minimum standard for the
assessment (including investigations) and management neonatal sepsis presenting from the
community; it does not replace or remove clinical judgement or the professional care and duty
necessary for each specific case.
Table of Contents
Purpose and Scope of PCPG ... 2
Flowchart - Neonatal fever/suspected sepsis presenting from the community 3
Important points .. 4
Abbreviations ... 4
Definitions .4
Differential diagnosis of a critically ill neonate 5
Serious Bacterial Infections in neonates . 5
HSV risk factors 6
Clinical features of sepsis .. 6
Assessment and Diagnosis ... 7
Clinical Assessment 7
Laboratory studies .. 7
Radiological studies 9
Further management .. 9
Empiric Antimicrobials ... 9
Antimicrobial Doses ..... 10
References .10
Acknowledgements .. 11
Document Ownership & History . 11
Neonatal Sepsis
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Flowchart - Neonatal fever/suspected sepsis presenting from the community.
NB: a neonate is any baby born at full term who is ?28 days old.
A premature baby is considered a neonate if corrected age ?44 weeks (see Neonatal fever/suspected
sepsis presenting from the community guideline for calculation of corrected age, available for download via the
SA Health Practice Guidelines website).
Neonatal Sepsis
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Important points
This guideline describes the recommended initial investigation and management of neonates
presenting from the community with fever or suspected sepsis with the exception of babies
admitted under the Neonatology team.
Abbreviations
CRP C-reactive protein
CSF Cerebrospinal fluid
CXR Chest X-ray
DIC Disseminated Intravascular Coagulation
EV Enteroviral
g/L gram per litre
GBS Group B streptococcus
HSV Herpes Simplex Virus
I/T immature-to-total ratio
IV Intronevous
kg kilogram
LFTs Liver function tests
LP Lumbar puncture
MC&S microscopy and susceptibility
mL millilitre
PCR polymerase chain reaction
NPA Nasopharyngeal aspirate
NSaline Normal Saline
PCR Polymerase chain reaction
SBI Serious bacterial infections
SPA Suprapubic aspiration
UTIs Urinary tract infections
VZV Varicella zoster virus
Definitions
Fever A fever is present when rectal temperature ?38oC. This correlates with
tympanic or axillary temp of 37.5oC.
Neonate A neonate is any baby born at full term (?37 weeks gestation) who is
?28 days old.
A premature baby is considered a neonate if their corrected age is
?44 weeks.
Corrected age is the actual age since birth in addition to the gestational
age at birth.
Sepsis For the purpose of these guidelines, a neonate with sepsis is any febrile or
unwell neonate in whom infection is suspected.
Neonatal Sepsis
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Differential diagnosis of a critically ill neonate
Sepsis
> Inborn errors of metabolism
> Cardiac abnormalities
> Endocrine crisis
> Electrolyte abnormalities
> Trauma accidental or non-accidental
> Seizure
Note:
o Fever in neonates includes both infectious and non-infectious causes.
o Viral infections are a common cause of fever. However, bacterial coinfection is not
uncommon.
o Incidence of SBI is higher in neonates compared with older children.
o The causative pathogens of sepsis are different in neonates compared with older
children.
o It is accepted that the use of antibiotics in all neonates with suspected sepsis will
result in neonates without bacterial infection receiving antibiotic therapy. These
guidelines emphasise appropriate investigations which will allow the tailoring (or
cessation) of antimicrobial therapy further on in the clinical course.
These guidelines refer to neonates who present for medical attention from the
community. For guidelines referring to neonates with onset of sepsis prior to leaving
hospital (both early and late-onset) please see the SA Perinatal Guidelines at
https://extapps2.sahealth.sa.gov.au/PracticeGuidelines/.
Serious Bacterial Infections in neonates
> SBI include bacteraemia, gastroenteritis, cellulitis, osteomyelitis, septic arthritis,
meningitis, pneumonia and, most commonly, UTIs.
> SBI can occur in the presence of concomitant viral infections, with as many as 10% of
patients with confirmed viral infections having UTIs or other SBIs.
> SBI can be caused by Gram negative bacteria, most commonly Escherichia coli, or Gram
positive organisms, most commonly GBS. Other Gram-negative pathogens such as
Klebsiella spp and Salmonella spp, along with Gram-positive pathogens, including
Streptococcus pneumoniae and Enterococcus spp, are less common but may occur.
> Neisseria meningitidis is a rare cause of bacterial infection in this age group and may
signal an underlying complement deficiency or, rarely, asplenia.
> Staphylococcus aureus is an increasing cause of bacterial infection in this age group and
often presents with concomitant skin infection.
> Listeria monocytogenes, once considered an important neonatal pathogen, has become
exceedingly rare in the last two decades.
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Neonatal Herpes Simplex (HSV) infection
Neonatal HSV infection is an important consideration in neonates with suspected sepsis.
Hepatic transaminase levels are elevated with disseminated HSV disease and severe sepsis.
HSV risk factors
*NB. These may not be present in all cases
Maternal:
> Maternal history of current or past HSV infections
> Maternal peri partum fever
> History of prolonged rupture of membranes
Neonatal:
> History of contact
> Scalp electrode monitoring
> Cutaneous vesicles and/or mucosal ulcers
> Seizures particularly focal seizures
> Elevated transaminases
For guidelines referring to the management of neonates with HSV infection, please see SA
Perinatal Practice Guidelines available at
https://extapps2.sahealth.sa.gov.au/PracticeGuidelines/.
Clinical features of sepsis
The clinical features of sepsis may be nonspecific and subtle. Neonates may present unwell
with one or more of the following symptoms and signs:
> Hypothermia, fever or temperature instability <36oC or >38oC
> Lethargy, poor cry or inconsolable crying feeding difficulties
> Altered behaviour/responsiveness
> Poor perfusion
> Altered muscle tone (e.g. floppiness)
> Not moving a limb
> Abnormal heart rate (bradycardia, tachycardia)
> Respiratory distress, apnoea
> Hypo or hyperglycaemia
> Metabolic acidosis
> Feed intolerance, including vomiting (bilious and non-bilious), abdominal distension
> Unexplained jaundice
> Umbilical flare or skin rashes
> Conjunctivitis
> Oliguria persisting >24 hours
> Unexplained excessive bleeding /abnormal clotting
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Assessment and Diagnosis
Clinical Assessment
1. ABC Treat any septic shock with sodium chloride 0.9% boluses up to 40 mL/kg,
obtain at least 2 vascular accesses, monitor urine output and assess conscious
level. Contact MedSTAR for retrieval/advice if in Rural Hospital. Once sepsis is
suspected, the IV antibiotics should be given within an hour.
2. Temperature measurement can be axillary, rectal or tympanic. Rectal temperature
is the gold standard to establish fever >38oC. This correlates with tympanic or
axillary temp of 37.5 oC.
Note:
o A response to antipyretic medication does not change the likelihood of an infant
having a serious bacterial infection.
o A fever documented at home by thermometer should be approached in the
same manner as fever recorded in hospital.
3. A thorough history and physical examination is required.
Note:
o Include questions about recent exposures, maternal risk factors at the time of
delivery, child s birth history and recent symptoms.
o Review any available microbiological results for mother (eg vaginal/placental
swabs, urine cultures) in case of resistant organisms.
o Clinical features of sepsis may be non-specific and subtle (see above).
Laboratory studies
It is recommended that the following studies be performed in neonates with suspected sepsis,
(with or without fever):
Blood
> Glucose.
> Blood cultures- ideally at least 1mL of blood.
> Sepsis multiplex PCR (HSV (1and 2), VZV, Enterovirus, Neisseria meningitides,
Streptococcus pneumoniae and Parechovirus).
> Complete blood count, differential and I/T ratio. An increase in the band count (>2) or
I/T ratio ? 0.2 (or 20%) is moderately predictive of sepsis.
> A low white cell count with neutropenia is also suspicious of sepsis.
> CRP has been studied in infants less than 90 days presenting with fever of unknown
source. A low CRP does not improve the confidence of ruling out SBI.
> Liver function tests.
> Lactate & acid base status
> Coagulation to check for DIC
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Cerebrospinal fluid
An LP should be performed to obtain CSF prior to starting antibiotics if it is thought safe to do
so. Antimicrobial therapy should not be delayed in order to perform an LP.
Request: microscopy (including Gram stain), culture and susceptibility, sepsis multiplex PCR,
which includes HSV (1 and 2), VZV, Enterovirus, Neisseria meningitides and Streptococcus
pneumoniae and Parechovirus. Protein, glucose (only if sufficient sample volume).
Note:
o The ideal volume of CSF is greater than 22 drops. This should be collected into
2 tubes.
o If less than 22 drops are obtained, contact microbiology to discuss priority of test
ordering.
o A suggested priority is: microscopy (1 drop required), then sterile site PCR (7 drops
required), then culture and susceptibility (10 drops required). Biochemistry (protein
and glucose) requires 4 drops and should be omitted if <22 drops obtained.
Interpretation of CSF
* Some studies have found up to 5% of white cells in neonates without meningitis comprise
neutrophils.
Note:
If CSF is abnormal, or unable to be obtained, the safest course is to treat as if there is
bacterial or HSV meningitis.
> Gram stain may be negative in up to 60% of cases of bacterial meningitis even without
prior antibiotics.
> Neither a normal Gram stain, nor a lymphocytosis excludes bacterial meningitis.
> Neutrophils may predominate in viral meningitis even after the first 24 hours.
> CSF findings in bacterial meningitis may mimic those found in viral meningitis (particularly
early on).
> Prior antibiotics usually prevent the culture of bacteria from the CSF. Antibiotics are
unlikely to significantly affect the CSF cell count or biochemistry in samples taken <24
hours after antibiotics. PCR may be useful in this situation.
> Recent studies do not support the earlier belief that seizures can increase cell counts in
the absence of meningitis. It is safest to assume that seizures do not cause an increased
CSF cell count.
> Some guidelines suggest that in traumatic taps 1 white blood cell can be allowed for every
500 to 700 red blood cells and 0.01g/L protein for every 1000 red cells. However, rules
based on a predicted white cell count in the CSF are not reliable.
Neutrophils (x 106 /L)
Lymphocytes
(x 106/L)
Protein
(g/L)
Glucose
(CSF: blood ratio)
Normal term
neonate
0* < 20 < 1.0 ? 0.6 (or ? 2.5 mmol/L)
Bacterial
meningitis
100-10,000
(but may be normal)
Usually < 100 > 1.0
(but may be normal)
< 0.4
(but may be normal)
Viral
meningitis
Usually <100 10-1000
(but may be normal)
0.4-1
(but may be normal)
Usually normal
Neonatal Sepsis
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Urine
SPA or urethral catheterisation is recommended for obtaining urine specimens. There is a
high rate of contamination of bag specimens.
Request: Urinalysis, urine culture, MC&S and urine HSV PCR.
Swabs
Swabs (1 swab from top to bottom) including eyes, throat, umbilicus and rectum and a
separate swab for any visible vesicles or lesions. Place in viral transport medium.
Request: HSV PCR
Faeces
To be collected depending on clinical context.
Request: Enteric micro (MC&S), enteric pathogens (PCR), EV PCR.
NPA or High Nasal Swab / Posterior pharyngeal throat swab
Request: respiratory viral PCR (also includes Bordetella pertussis and Mycoplasma
pneumoniae PCR).
Radiological studies
> It is recommended that a Chest X-ray is performed as part of the sepsis work-up.
Consider Neuroimaging if there is an encephalitic picture or if suspected meningitis which
isn t improving with recommended antibiotic regime, as may be a cerebral abscess
> ECHO
> Enteroviral infection may be associated with a myocarditis so arrange echo if clinically
suspicious.
Further management
> It is recommended that all neonates presenting from the community with suspected sepsis
be admitted to hospital for further evaluation and management.
> Empiric antimicrobial therapy should be initiated as soon as possible (see below).
> If there are signs consistent with a specific pathogen, e.g. skin infection suggestive of
Staph aureus, directed therapy may be appropriate. Discuss with specialist.
Empiric Antimicrobials
> Modify according to clinical picture, specimen culture and susceptibility results.
Note:
o It is recommended that, if a lumbar puncture has not been performed prior to
antibiotic therapy, it is performed as soon as is safely possible afterwards.
o Note there are reports that EV and bacterial meningitis can co-exist.
Community-onset sepsis (meningitis not excluded):
IV cefotaxime PLUS IV amoxicillin PLUS IV aciclovir
Duration of treatment depends on organisms isolated and clinical presentation.
Community-onset sepsis (meningitis excluded):
IV amoxicillin PLUS IV gentamicin PLUS consider adding IV aciclovir if clinically
indicated.
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For neonates at increased risk of MRSA infection add IV vancomycin to the above regimens.
Duration of treatment depends on organisms isolated and clinical presentation
Antimicrobial Doses
Cefotaxime
> Refer to Neonatal Medication Guidelines for dose regimens
www.sahealth.sa.gov.au/neonatal
Amoxicillin
> Refer to Neonatal Medication Guidelines for dose regimens
www.sahealth.sa.gov.au/neonatal
Gentamicin
> Refer to Neonatal Medication Guidelines for dose regimens
www.sahealth.sa.gov.au/neonatal
Aciclovir
> Refer to Neonatal Medication Guidelines for dose regimens
www.sahealth.sa.gov.au/neonatal
Vancomycin
> Refer to Neonatal Medication Guidelines for dose regimens
www.sahealth.sa.gov.au/neonatal
References
Several Guideline sites were consulted for existing guidelines regarding neonatal sepsis
presenting from the community, including:
1. Royal Children s Hospital. 2017 Clinical Practice Guidelines Sepsis assessment and
management. [ONLINE] Available at:
https://www.rch.org.au/clinicalguide/guideline_index/SEPSIS_assessment_and_management/.
[Accessed 4 July 2018]
2. Australian Government National Health and Medical Research Council. 2018.
Therapeutic guidelines antibiotic version 15. [ONLINE] Available at:
https://www.clinicalguidelines.gov.au/portal/2406/therapeutic-guidelines-antibiotic-version-15.
[Accessed 4 July 2018]
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Acknowledgements
The South Australian Child and Adolscent Health Community of Practice gratefully
acknowledge the contribution of clinicians and other stakeholders who participated throughout
the guideline development process particularly:
Write Group Lead
Dr Kavita Rasiah
Write Group Members
Dr Brett Ritchie
Dr Gillian Watterson
Ulrik Lorenzen
Carey Aylmer
SA Paediatric Clinical Practice Guidelines Reference Group Members
Document Ownership & History
Developed by: SA Child & Adolescent Health Community of Practice
Contact: Health.PaediatricClinicalGuidelines@sa.gov.au
Endorsed by: Commissioning and Performance, SA Health
Next review due: 26/06/2025
ISBN number: 978-1-74243-904-4
PDS reference: CG337
Policy history: Is this a new policy (V1)? Y
Does this policy amend or update and existing policy? N
If so, which version?
Does this policy replace another policy with a different title? N
If so, which policy (title)?
Approval
Date Version
Who approved
New/Revised Version
Reason for Change
26/06/20 V1
Lynne Cowan, Deputy CE,
Commissioning and Performance, SA
Department for Health and Wellbeing
Original Commissioning and
Performance approved version
Purpose and Scope of PCPG
Flowchart - Neonatal fever/suspected sepsis presenting from the community.
Important points
Abbreviations
Definitions
Differential diagnosis of a critically ill neonate
Serious Bacterial Infections in neonates
HSV risk factors
Clinical features of sepsis
Assessment and Diagnosis
Clinical Assessment
Laboratory studies
Radiological studies
Further management
Empiric Antimicrobials
Antimicrobial Doses
References
Acknowledgements
Document Ownership & History
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