Neonatal sepsisBMJ 2020; 371 doi: https://doi.org/10.1136/bmj.m3672 (Published 01 October 2020) Cite this as: BMJ 2020;371:m3672
All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
This is a very well written article on neonatal sepsis, but I thought it is worth noting that, in developing countries, Group B Streptococcus is a relatively uncommon microbial cause of neonatal sepsis (responsible for only 2-8% of cases in developing countries). Klebsiella species, E. coli and S. aureus are the more common microbial causes.(1) The predominance of these Gram-negative organisms likely relates to poor infection control at or around the time of delivery, and is likely due to horizontal rather than vertically transmission from the mother. In addition, when preterm and very low birth weight (VLBW) infants are investigated separately, the cases of disease attributable to Gram-negative rods and E. coli is increased, making Gram-negative sepsis the most common cause of early-onset sepsis in this population group.(2)
Viral infections, including herpes simplex virus (HSV), enteroviruses, and parechoviruses should also be considered in the differential diagnosis, and is essential to be clinically differentiated from bacterial sepsis. Neonatal herpes simplex virus can present with signs and symptoms that are indistinguishable from those of neonatal bacterial sepsis.(2) In these patients, the bacterial cultures might come back negative, and patients should have swab specimens taken from mucous membranes, mouth and skin, if vesicular lesions are present on the skin.
Lastly, the Kaiser Permanente Neonatal Early-Onset Sepsis Calculator might be also worth mentioning- a scoring system developed in attempt to predict the risk of neonatal sepsis, reduce unnecessary antibiotic exposure and guide management. It is mainly for infants born ≥34 week gestation, and uses specified maternal risk factors along with the infant’s clinical presentation to estimate the risk of early-onset sepsis at birth.(3)
1. Waters D, Jawad I, Ahmad A, et al. Aetiology of community-acquired neonatal sepsis in low and middle income countries. J Glob Health 2011 Dec; 1(2): 154-170
2. Simonsen KA, Anderson-Berry AL, Delair SF, Davies HD. Early-Onset Neonatal Sepsis. Clin Microbiol Rev 2014 Jan; 27(1): 21-47 doi: 10.1128/CMR.00031-13
3. Neonatal Early-Onset Sepsis Calculator. Kaiser Permanente Research. https://neonatalsepsiscalculator.kaiserpermanente.org/InfectionProbabili...
Competing interests: No competing interests
Re: Neonatal sepsis
The author identifies many relevant learning points for all health professionals who assess infants in the neonatal period. As this covers the first 28 days, the relevance of late onset sepsis is highlighted when the initial observations depend on parental awareness of signs of illness and so this should be emphasised at discharge from maternity care with an agreed pathway for advice and referral.
Group B beta haemolytic streptococcus is a recognised pathogen causing late onset neonatal sepsis, is acquired from a colonised mother and remains a risk for recurrence in subsequent pregnancies. One of the important actions required in management is to inform the mother to be prepared to consider accepting intrapartum antibiotic treatment in her future pregnancies. It may also be possible to update the woman's maternity records with the relevant alert.
Neonatal infection (early onset): antibiotics for prevention and treatment. Clinical guideline [CG149]
Competing interests: No competing interests