Management of Neonates With Suspected or Proven Early-Onset Bacterial Sepsis

TLDR

Early‑onset neonatal sepsis, though less frequent due to improved obstetric care, remains a leading cause of morbidity and mortality in preterm infants, yet risk identification and diagnostic tests are insensitive, leading clinicians to often extend broad‑spectrum antibiotic therapy beyond what is necessary. The report aims to provide a practical, evidence‑based strategy to discontinue empirical antibiotics at 48 h when sepsis risk is low, thereby reducing unnecessary treatment. Data show that prolonged empirical therapy (≥5 days) in preterm infants is linked to higher rates of late‑onset sepsis, necrotizing enterocolitis, and mortality.

Abstract

With improved obstetrical management and evidence-based use of intrapartum antimicrobial therapy, early-onset neonatal sepsis is becoming less frequent. However, early-onset sepsis remains one of the most common causes of neonatal morbidity and mortality in the preterm population. The identification of neonates at risk for early-onset sepsis is frequently based on a constellation of perinatal risk factors that are neither sensitive nor specific. Furthermore, diagnostic tests for neonatal sepsis have a poor positive predictive accuracy. As a result, clinicians often treat well-appearing infants for extended periods of time, even when bacterial cultures are negative. The optimal treatment of infants with suspected early-onset sepsis is broad-spectrum antimicrobial agents (ampicillin and an aminoglycoside). Once a pathogen is identified, antimicrobial therapy should be narrowed (unless synergism is needed). Recent data suggest an association between prolonged empirical treatment of preterm infants (≥5 days) with broad-spectrum antibiotics and higher risks of late onset sepsis, necrotizing enterocolitis, and mortality. To reduce these risks, antimicrobial therapy should be discontinued at 48 hours in clinical situations in which the probability of sepsis is low. The purpose of this clinical report is to provide a practical and, when possible, evidence-based approach to the management of infants with suspected or proven early-onset sepsis.