1. Term / symptomatic / pretreated

• Culture
• Treat
• Reassess clinical status and culture results at 48 hours; if the blood culture is negative (see Blood Culture Sensitivity and Specificity Study), and CSF studies benign, make a decision to discontinue antibiotics, or continue for 72 hours (see Forty-eight vs. Seventy-two hour Blood Culture Positivity Studies).
• Stop anitbiotics if cultures are negative, no maternal GBS or amnionitis and clinical course not compatible with infection
• If cultures positive or infants symptomatic with signs of sepsis or strong maternal risk factors for sepsis (see Maternal Risk Factors) treat for 10 days (blood culture positive) or 14 to 21 days (CSF culture positive)

2. Term / symptomatic / not pretreated

• Culture
• Treat
• Reassess clinical status and culture results at 48 hours; if the blood culture is negative (see Blood Culture Sensitivity and Specificity Study), and CSF studies benign, make a decision to discontinue antibiotics, or continue for 72 hours (see Forty-eight vs. Seventy-two hour Blood Culture Positivity Studies).
• Stop antibiotics if cultures are negative and clinical course not suggestive of infection
• If cultures positive, treat for 10 days (blood culture positive) or 14-21 days (CSF culture positive)

3. Term / asymptomatic / pretreated

• Observe closely for 48 hours (if maternal amnionitis or GBS colonization or infection consider a rule out sepsis -- blood/CSF cultures and antibiotics for 48 hours)

4. Term / asymptomatic / not pretreated

• No cultures or treatment; observe closely for 24 hours if there are maternal risk factors

5. Premature / symptomatic / pretreated

• Culture
• Treat
• Reassess at 72 hours
• Generally continue antibiotics for 10 day treatment course. Can consider stopping antibiotics if infant has a clinical course not suggestive of infection and cultures are negative. Continuation of the signs and symptoms and/or occurrence of new signs or symptoms of infection are indications to continue antibiotics

6. Premature / symptomatic / not pretreated

• Culture
• Treat
• Reassess at 72 hours
• Treat for a full course, 10 days for a positive blood culture and 14-21 days for a positive CSF culture

7. Premature / asymptomatic / pretreated

• Culture
• Treat
• Reassess at 72 hours
• Stop antibiotics if infant is asymptomatic or clinical course not suggestive of infection and cultures are negative

8. Premature / asymptomatic / not pretreated

• No workup or treatment for infants >1250 g birthweight and 30 weeks gestation
• For infants below 1250 g birthweight and 30 weeks gestation:
  • Culture
  • Treat
  • Reassess at 72 hours
  • Stop antibiotics if infant is asymptomatic or clinical course not suggestive of infection and cultures are negative

Culture

Obtain blood culture (target blood culture volume = 1.0 mL., see Blood Culture Volume Study); CSF culture; and CSF cell count

Treat

Start I.V. antibiotics

• if term
  • ampicillin 100 mg/kg q12hr and gentamicin 2.5 mg/kg q12hr if CSF cell count WNL
  • OR ampicillin 150 mg/kg q12hr and cefotaxime 50 mg/kg q12hr if CSF cell count abnormal or if spinal tap was unsuccessful
• if premature
  • ampicillin 100 mg/kg q12hr and gentamicin 2.5 mg/kg q18hr (q24hr if < 28 weeks gestation) if CSF cell count WNL
  • OR ampicillin 150 mg/kg q12hr and cefotaxime 50 mg/kg q12hr if CSF cell count abnormal or if spinal tap was unsuccessful

Blood Culture Volume Study

Schelonka et al. (J. Pediatr. 129:275-8, 1996) have demonstrated that for detecting low colony count bacteremia 1 mL of blood is minimum volume.

Blood Culture Sensitivity and Specificity Study

An autopsy study involving infants with pathologic evidence of infection, blood culture sensitivity was 82% (32 of 39 premortum cultures were positive); and specificity was 96% (48 of 50 cultures were negative) Pediatr 64:60-64, 1979.

Forty-eight vs. Seventy-two Hour Blood Culture Positivity Studies

Kurlar et al. Time to positivity for detection of bacteremia in neonates. J Clin Microb 27:1068-1071, 1989

Pichichero et al. Detection of neonatal bacteremia. J Pediatr 94:958-960, 1979.

Rowley et al. Incubation period necessary to detect bacteremia in neonates. Ped Infect Dis 5:590-591, 1986.

Ruderman et al. Quantitative blood cultures in the diagnosis of sepsis in infants with umbilical and Broviac catheters. J Pediatr 112:748-751, 1988.

Maternal Risk Factors (listed in order of estimated importance)

• GBS colonization
• Intraamnionitic infection (amnionitis)
• Prolonged rupture of membranes (greater than 18 hours)
• Maternal fever (>38.0º C.) during labor

Infant Symptomatic

• O₂ requirement
• respiratory distress
• apnea
• lethargy
• poor feeding

Mother Pretreated

If mother received antibiotics >= 4 hours prior to delivery, this is considered pretreated.