This document describes a case study of a neonatal baby presenting with signs of sepsis. The baby is pale, floppy and has cool peripheries. Initial management involves resuscitation and investigations including blood cultures, urine culture, full blood count and C-reactive protein. Antibiotics are started for suspected early onset sepsis. Blood cultures later grow Group B Streptococcus. The baby requires intubation for respiratory support. Treatment is continued with antibiotics targeting GBS. The parents are informed of the diagnosis and prognosis, and told the baby is currently responding well to targeted treatment.

1. Neonatal case study scenario
DR MOHAMED ABDELAZIZ ALI
january 2014

2. you are called to the postnatal ward to review a
baby is 8 hours old.
The midwife reported that the baby not feeding
well.his mother says he is tried to feed after birth
but now is not interested.on examination,the
infant pale,and feels slightly floopy.he is mottled
with cool peripheries and has heart rate of 160
bpm and mild recession.he has normal heart
sounds.and both femoral pulses can be felt.

3. What is your first management step?

The baby should be resuscitated using ABC
approach and taken to the neonatal unit for
ongoing care and management.

4. What questions if any do you ask the
mother?
Ask about possible events that may make
infection more likely.
1-ask about prolonged ruptur of membranes ?
2-ask did the mother have any episodes of
increased temperature ?
3-ask if there have been any previous pregnancies
were any infants treatedfor infection ?
4-ask about UTIs ?
5-ask about premature birth,pre-eclampsia and
LBW infants ?


5. List investigations you should carry
out?
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1-Blood culture:
Is the definitive test.
The majority of blood culture taken will grow in
48 Hs if they are going to be positive.
The majority of neonatal infections are associated
with a bacteraemia and thus a +ve blood culture.
2-urine culture:
Is important investigation if sepsis is suspected.
If the baby is unwell and septic,the easiest way to
obtain a sample is by suprapubic aspiration of the
urine

6.  If a bag urine specimen is thought to be
positive,it must have at least 150 white cells mm 3 /
and a pure growth more than 100 000
organisms/ml urine.


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3-Full bood count:
Differential white count of help.
Low neutrofil count,<2.0-2.5 * 109 /L in the frist 2
days of life suggest that there is bacterial inf.
Other helpful markers of infection may be the
ratio of mature to total number of neutrophils,the
maximum acceptable value for excluding sepsis in
the first 24 Hs is 0.16 and the ratio falls to 0.12
within 60 Hs and if this ratio > 0.2 is a good
marker for infection.

7. 4- c-reactive protein:


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Is a good indicator of infection if serial
measurements are made.
It is better than WBCs indices as an inf marker.
It takes few Hs to rise therefor should not be used
to decide when start antibiotics.
Culture-proven sepsis is unlikly if CRP does not
rise within 48 Hs of the onset of illness ,and thus
generally safe to stop antibiotic if the cultures are
-ve and CRP normal at 48Hs.
5- chest X-ray:
all infants suspected sepsis should have chest xray.
6-procalcitonin and CRP concentration in
umblical cord….(new,have high specifity and
sensitivity).

8. What is your next step in managing
this baby?



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After
resuscitation
,stabilisation
and
investigations, antibiotic should be given
immediately.
For early onset sepsis (most likely in this infant
case) the antibiotics need to cover group B
Streptoccus,listeria,and gram –ve organisms such
as E. coli.
A combination of penicillin and gentamicin
would be a good choice as there is action
between the two against GBS.
Cephalosporin alone will have no coverage for
E.coli or listeria.

9. The results of initial ivestigations are obtained:
Hb
14.7 g/ dL
WBCs
21.4 * 109 /L
Neut
1.7 * 109 /L
Plt
104 * 109 /L
CRP
94 mg /L
 urine SPA sample – no cells, no organism.
CXR shows diffuse, fine, reticluglanular pattern,
much like seen in RDS.
The infant breathing without ventilatory support
with some low flow oxygen to maintain his
saturation.he has had his frist dose of antibiotics
and currently on maintained fluid.




10. What do you do now ?


In this situation which a high CRP would carry
out a lumber puncture.
if the platlet count < 50,000, then a platlet
transfusion should be given before the lumber
puncture.

11. 

A lumber puncture is carried out, results:
RBCs
18000 / mm3
WBCs
12/ mm3
protein
2.5 g/L
Glucose
1.4 mmol/L
CSF is moderately blood stained.
6 Hs later the infant is more symptomatic
having frequent apneas and desaturations. He
is intubated and ventilated .repeated bloods
show the following results:
CRP
120 mg/L
Platelets
45 * 109 /L
Neutroohils 0.8 * 109 /L

12. Which of the following treatment consider ?
1- Fresh frozen plasma (FFP).
2-Immunoglobulins.
3-Exchange transfusion.
4-Platlets transfusion.
5-Changing antibiotics.
6-Granulocyte-macrophage colony
factor (GM-CSF)
stimulating

13. 
The are phone call from the microbiology
department the following daysaying the blood
cultures are growing Group B streptococcus.
The infant CRP is now 40 mg/L and platelets
stable above 100 after the platelet transfusion.

14. How you modify your treatmen,if at all?
Therapy can be simplified to intravenous benyl
penicillin alone as GBS is very sensitive to this.
How long will you treat the baby?
 without meningitis ,GBS bacteraemia can be

treated with antibiotics for 10 days.
If meningitis was also present, antibiotic should
be continued for at least 21 days.

15. What will you tell the parents?
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Up to 30% of pregnant women are colonised GBS
The majority of neonatal inf present within 4-6 Hs
of life and about 90% of cases present within 24
Hs of life.
His infection was picked up early and treatment
commenced promptly.
His infective markers are improving showing he
is responding to treatment.
The baby has no signs of menigitis and is on the
correct antibiotics with maximum supportive ttt.
Previously,mortality from GBS was about 50%
with a mortality rate up to 100% for
babies<1.5kg. Currently in UK the mortality rate
is 10%.
At this stage we would be cautiously optimistic
the parent.

16. thank you