Rosen & Barkin's 5-Minute Emergency Medicine Consult (480 page)

• Bacterial:
  
  • Group B Streptococcus
    
  • Escherichia coli
    
  • Listeria monocytogenes
    
  • Coagulase-negative Staphylococcus
    
  • Treponema pallidum
    
• Viral:
  
  • Herpes simplex is a common viral etiology.
    
  • Enterovirus
    
  • Adenovirus
    
• Fungi:
  
  • Candida species
    
• Protozoa:
  
  • Malaria
    
  • Borrelia
    

• Bacterial:
  
  • Group B Streptococcus
    
  • E. coli
    type K1
    
  • L. monocytogenes
    
  • Other streptococci
    
  • Nontypeable
    Haemophilus influenzae
    
  • Coagulase-positive and coagulase-negative Staphylococcus
    
  • Less commonly: Klebsiella
    ,
    Enterobacter
    
  • Pseudomonas, T. pallidum,
    and
    Mycobacterium tuberculosis
    
  • Citrobacter diversus
    (important cause of brain abscess)
    
  • Additional pathogens: Mycoplasma hominis
    and
    Ureaplasma urealyticum
    
• Viral:
  
  • Enteroviruses
    
  • Herpes simplex virus (type 2 more commonly)
    
  • Cytomegaloviruses
    
  • Toxoplasma gondii
    
  • Rubella
    
  • HIV
    
• Fungi:
  
  • Candida albicans
    and other fungi
    

DIAGNOSIS

• Nonspecific history:
  
  • “Not acting normal”
    
  • Feeding poorly
    
  • Irritable or lethargic
    
• General:
  
  • Toxic appearing
    
  • Altered mental status: Irritable or lethargic
    
  • Apnea or bradycardia
    
  • Mottled, ashen, cyanotic, or cool skin
    

• Vital signs:
  
  • Hyperthermia/hypothermia
    
  • Tachypnea
    
  • Tachycardia
    
  • Prolonged capillary refill time
    
• Abdominal distention
  
• Jaundice
  
• Bruising or prolonged bleeding
  
• Sepsis syndrome in the neonate:
  
  • Septic shock
    
  • Hypoglycemia
    
  • Seizures
    
  • Disseminated intravascular coagulation (DIC)
    
  • If untreated, cardiovascular collapse and death
    

• Sepsis evaluation followed by empiric antibiotics and support
  
• Determine a source for the infection.
  
• Identify metabolic abnormalities.
  

• Bedside glucose determination
  
• CBC:
  
  • WBCs elevated or suppressed
    
  • Shift to the left
    
  • Thrombocytopenia
    
• C-reactive protein (CRP)
  
• Urinalysis
  
• Cultures as soon as the diagnosis is entertained:
  
  • Blood, CSF, catheterized or suprapubic urine, stool
    
• Lumbar puncture:
  
  • May need to delay if hemodynamically unstable
    
  • Cell count, protein, glucose, culture, Gram stain
    
• Serum glucose needed to exclude hypoglycemia
  
• Arterial blood gas and oximetry
  
  • Metabolic acidosis is common.
    
• Electrolytes and calcium:
  
  • Hyponatremia
    
  • Hypocalcemia
    
• DIC panel:
  
  • Coagulopathy is a late complication.
    
  • Monitor PT, PTT and fibrinogen-split products
    

CXR to rule out pneumonia

• Heart disease:
  
  • Hypoplastic left heart syndrome
    
  • Myocarditis
    
• Metabolic disorders:
  
  • Hypoglycemia
    
  • Adrenal insufficiency (congenital adrenal hyperplasia)
    
  • Organic acidoses
    
  • Urea cycle disorders
    
• Intussusception
  
• Child abuse
  
• CNS:
  
  • Intracranial hemorrhage
    
  • Perinatal asphyxia
    
• Neonatal jaundice
  
• Hematologic emergencies:
  
  • Neonatal purpura fulminans
    
  • Severe anemia
    
  • Methemoglobinemia
    
  • Malignancy (congenital leukemia)
    

TREATMENT

• Ventilatory support if obtunded, apneic, or respiratory distress
  
• IV access
  
• Continuous monitoring
  

• Implement empiric treatment for neonatal sepsis if presentation at all consistent, particularly if any risk factors are present.
  
• Administer antibiotics:
  
  • Ampicillin and gentamicin or cefotaxime
    
  • Add vancomycin if the patient’s condition continues to deteriorate or any suggestion of
    Streptococcus pneumoniae
    .
    
  • Cefotaxime may be substituted for gentamicin.
    
• Support for septic shock if present
  

• Ampicillin: 200 mg/kg/d q6h IV/IM for infant >2 kg birth weight and >2 wk old; 150 mg/kg/d q8h if <7 days old
  
• Cefotaxime: 150 mg/kg/d q6h IV/IM for infants >2 kg birth weight and >1 wk old; 150 mg/kg/d q8h IV/IM if 8–28 days old; 100 mg/kg/d IV/IM q12h if 0–7 days old
  
• Gentamicin: 2.5 mg/kg/dose q8h IV/IM if postconceptual age >37 wk and >7 days old; 2.5 mg/kg/dose q12h if <7 days old
  
• Vancomycin: 15 mg/kg/dose IV q8h if postconceptual age >37 wk and >7 days old; 15 mg/kg IV q12h if <7 days old
  

FOLLOW-UP

• All patients with suspected sepsis are admitted to the hospital for supportive care, IV antibiotic therapy, and close monitoring.
  
• All children <1 mo with a fever are generally admitted even in the absence of significant suspicion of sepsis. Older children are admitted based upon the clinical presentation.
  

• Airway management indicated if obtundation, apnea, or respiratory distress
  
• IV access to administer fluids and pressors as needed
  
• Continuous monitoring
  

• American Academy of Pediatrics.
  Red Book: 2012 Report of the Committee on Infectious Diseases
  . 29th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2012.
  
• Edwards MS. Postnatal bacterial infections. In: Martin RJ, Fanaroff AA, Walsh MC, eds.
  Neonatal-Perinatal Medicine. Diseases of the Fetus and Infant
  . 9th ed. St. Louis, MO: Mosby; 2011:793–829.
  
• Ferrieri P, Wallen LD. Neonatal bacterial sepsis. In: Taesch HW, Ballard RA, Gleason CA.
  Avery’s Diseases of the Newborn
  . 9th ed. Philadelphia, PA: Elsevier Saunders; 2012:538–550.
  
• Shapiro NI, Zimmer GD, Barkin AZ. Sepsis syndromes. In: Marx JA, Hockberger RS, Walls RM, eds.
  Rosen’s Emergency Medicine: Concepts and Clinical Practice
  . 7th ed. St. Louis, MO: Mosby; 2010:1848–1858.
  
• Van de Hoogen A, Gerards LJ, Verboon-Maciolek MA, et al. Long-term trends in the epidemiology of neonatal sepsis and antibiotic susceptibility of causative agents.
  Neonatology
  . 2010;97(1):22–28.
  
• Young TE, MangumB.
  Neofax 2011: A Manual of Drugs Used in Neonatal Care
  .24th ed. Montvale, NJ: Physicians’Desk Reference; 2011:2–105.
  

CODES

• 038.0 Streptococcal septicemia
  
• 038.42 Septicemia due to escherichia coli [E. coli]
  
• 771.81 Septicemia [sepsis] of newborn
  

BASICS