Neonatal bacterial infection and sepsis: Case

This preterm infant at 3 weeks of age is at high risk for late-onset sepsis. Prematurity, very low birth weight, prolonged NICU stay, and a central venous catheter in situ for 12 days are the dominant risk factors. Coagulase-negative staphylococci account for nearly half of all late-onset sepsis episodes in very low birth weight infants in the NICHD Neonatal Research Network. [1]

Clinical findings

The presenting signs — increasing apnoea, temperature instability, and a raised CRP — are classic but non-specific features of late-onset sepsis in the preterm infant. The differential includes culture-negative clinical sepsis, catheter-related bloodstream infection, necrotising enterocolitis, and metabolic deterioration. A full septic workup is mandatory: blood culture from a peripheral site and from the central line, complete blood count, CRP, and urine culture by suprapubic aspiration or sterile catheterisation. A lumbar puncture is indicated if the infant is stable enough and meningitis is clinically suspected. [1]

Management

Start empiric antibiotics after obtaining cultures. For suspected late-onset sepsis in a preterm infant with a central line, the empiric regimen should include anti-staphylococcal cover. Vancomycin is appropriate when coagulase-negative staphylococci are the most likely pathogen, combined with gentamicin for Gram-negative coverage. Remove the central venous catheter promptly if bacteraemia persists, as catheter retention is a major risk factor for treatment failure and metastatic infection. [2]

Stewardship and follow-up

Once the organism and sensitivities are identified, narrow the antibiotic spectrum. For coagulase-negative staphylococcal line infection with catheter removal, 5 to 7 days of targeted therapy is usually sufficient. Longer courses are needed if the line remains in situ or if there is evidence of metastatic infection. Repeat CRP and blood cultures to document clearance. Ensure therapeutic drug monitoring for vancomycin and gentamicin. [2]

Long-term follow-up is essential. Preterm infants who experience late-onset sepsis have higher rates of adverse neurodevelopmental outcomes compared with uninfected peers, including increased risk of cerebral palsy, cognitive impairment, and developmental delay. Arrange structured developmental follow-up with audiology and neurological assessment at corrected ages 6 and 12 months. [3]