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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 &amp; 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&amp;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 
&gt; Inborn errors of metabolism 

&gt; Cardiac abnormalities 

&gt; Endocrine crisis 

&gt; Electrolyte abnormalities 

&gt; Trauma   accidental or non-accidental 

&gt; 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 
&gt; SBI include bacteraemia, gastroenteritis, cellulitis, osteomyelitis, septic arthritis, 

meningitis, pneumonia and, most commonly, UTIs.  

&gt; 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. 

&gt; 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.  

&gt; Neisseria meningitidis is a rare cause of bacterial infection in this age group and may 
signal an underlying complement deficiency or, rarely, asplenia.  

&gt; Staphylococcus aureus is an increasing cause of bacterial infection in this age group and 
often presents with concomitant skin infection.  

&gt; 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: 

&gt; Maternal history of current or past HSV infections 

&gt; Maternal peri partum fever 

&gt; History of prolonged rupture of membranes 

Neonatal: 

&gt; History of contact 

&gt; Scalp electrode monitoring 

&gt; Cutaneous vesicles and/or mucosal ulcers 

&gt; Seizures   particularly focal seizures 

&gt; 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:  

&gt; Hypothermia, fever or temperature instability &lt;36oC or &gt;38oC 

&gt; Lethargy, poor cry or inconsolable crying feeding difficulties 

&gt; Altered behaviour/responsiveness 

&gt; Poor perfusion 

&gt; Altered muscle tone (e.g. floppiness) 

&gt; Not moving a limb 

&gt; Abnormal heart rate (bradycardia, tachycardia) 

&gt; Respiratory distress, apnoea 

&gt; Hypo or hyperglycaemia  

&gt; Metabolic acidosis 

&gt; Feed intolerance, including vomiting (bilious and non-bilious), abdominal distension 

&gt; Unexplained jaundice 

&gt; Umbilical flare or skin rashes 

&gt; Conjunctivitis 

&gt; Oliguria persisting &gt;24 hours 

&gt; 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 &gt;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 

&gt; Glucose. 

&gt; Blood cultures- ideally at least 1mL of blood. 

&gt; Sepsis multiplex PCR (HSV (1and 2), VZV, Enterovirus, Neisseria meningitides, 
Streptococcus pneumoniae and Parechovirus).  

&gt; Complete blood count, differential and I/T ratio. An increase in the band count (&gt;2) or 
I/T ratio ? 0.2 (or 20%) is moderately predictive of sepsis.  

&gt; A low white cell count with neutropenia is also suspicious of sepsis. 

&gt; 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. 

&gt; Liver function tests. 

&gt; Lactate &amp; acid base  status 

&gt; 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 &lt;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.  

&gt; Gram stain may be negative in up to 60% of cases of bacterial meningitis even without 
prior antibiotics. 

&gt; Neither a normal Gram stain, nor a lymphocytosis excludes bacterial meningitis. 

&gt; Neutrophils may predominate in viral meningitis even after the first 24 hours. 

&gt; CSF findings in bacterial meningitis may mimic those found in viral meningitis (particularly 
early on).  

&gt; 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 &lt;24 
hours after antibiotics. PCR may be useful in this situation. 

&gt; 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. 

&gt; 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*  &lt; 20 &lt; 1.0 ? 0.6 (or ? 2.5 mmol/L) 

Bacterial 
meningitis 

100-10,000 
(but may be normal) 

Usually &lt; 100 &gt; 1.0 
(but may be normal) 

&lt; 0.4 
(but may be normal) 

Viral 
meningitis 

Usually &lt;100 10-1000 
(but may be normal) 

0.4-1 
(but may be normal) 

Usually normal 



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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&amp;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&amp;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 
&gt; 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 

&gt; ECHO 

&gt; Enteroviral infection may be associated with a myocarditis so arrange echo if clinically 
suspicious. 

Further management 
&gt; It is recommended that all neonates presenting from the community with suspected sepsis 

be admitted to hospital for further evaluation and management. 

&gt; Empiric antimicrobial therapy should be initiated as soon as possible (see below). 

&gt; 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 
&gt; 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 

&gt; Refer to Neonatal Medication Guidelines for dose regimens  
www.sahealth.sa.gov.au/neonatal  

Amoxicillin 

&gt; Refer to Neonatal Medication Guidelines for dose regimens  
www.sahealth.sa.gov.au/neonatal  

Gentamicin 

&gt; Refer to Neonatal Medication Guidelines for dose regimens  
www.sahealth.sa.gov.au/neonatal  

Aciclovir  

&gt; Refer to Neonatal Medication Guidelines for dose regimens  
www.sahealth.sa.gov.au/neonatal  

Vancomycin 

&gt; 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 &amp; History 
Developed by: SA Child &amp; 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 &amp; History

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