Epidemiology of

neonatal sepsis
C AM IL L A B R IM B LE , SO P H IE B AR RE TT , M ATT H E W BYOTT , S H E R IN
C H AC KO , S AM GO UL D , H AN N AH B ROO K S, AB D UL AB D UL L AH ,
RAB AB AH M AD

What is the definition of

sepsis?
Sepsis is the condition that develops following an infection/insult and is accompanied by SIRS
symptoms
SIRS stands for Systemic Inflammatory Response syndrome. Under the 1992 guidelines, SIRS is
diagnosed by two or more of the following conditions:
oBody temperature >38C or <36C
oHeart rate higher than 90 bpm
oRespiratory rate higher than 20/min, or PaCO lower than 32mmHg
oWBC count > 12,000 cells/l or < 4,000/ l

Sepsis = SIRS + confirmed infection

Newer PIRO system for staging sepsis

460-370BC

979-1037

1688-1738

Hippocrates

Ibn Sina

Hermann
Boerhave

1818-1865

1822-1895

1827-1912

1867-1936

Semmelweis

Lois Pasteur

Joseph Lister

H.Lennhartz

WWII

1967
onwards

Early Onset Sepsis:

Definition: Neonatal early-onset sepsis (EOS) is defined as blood or cerebrospinal fluid
culture-proven bacterial infection of the newborn occurring in the first 7 days of life
(Mukhopadhyay and Puopolo 2012).
Of newborns with early-onset sepsis, 85% present within 24 hours, 5% present at 2448 hours, and a smaller percentage present within 48-72 hours. Onset is most rapid in
premature neonates.
The microorganisms most commonly associated with early-onset sepsis include the
following:
-Group B Streptococcus (GBS)
-Escherichia Coli
-Coagulase-negative Staphylococcus
-Hameophilus influenzae
-Listeria monocytogenes
(Anderson-Berry 2014)

The overall incidence of EOS in

the United States was 3-4 cases
per 1000 live births just prior to
the first Centers for Disease
Control and Prevention (CDC)
guideline recommending the use
of intrapartum antibiotic
prophylaxis (IAP) to prevent
perinatal Group B Streptococcus
(GBS) disease (1-4)
With the widespread use of intrapartum antibiotic therapies the incidence
of neonatal early onset sepsis has declined.

Currently the incidence of GBS-specific EOS has declined to 0.3-0.4 cases

per 1000 live births, and overall EOS incidence has declined to 0.8-1.0
cases per 1000 live births
(Mukhopadhyay and Puopolo

Late Onset
Neonatal
Sepsis
Definition: Clinical syndrome of
systemic illness caused by
bacteria within the first month of
life. Late-onset Sepsis (LOS)
after >7days but <30days (after
72hours of life but <30days).
Common Causative Agents:
-Coagulase-negative
staphylococcus.
-Staphylococcus Aureus
-Enterobacteriaceae (majority)

The majority of LOS episodes were caused by Gram-positive

organisms (59.4%, 477/803), followed by Gram-negative
organisms (30.7%, 247/803) and yeast (7.7%, 62/803)

-Fungal-Candida

Early and Late Onset Sepsis in Late Preterm Infants - Pediat

Infectious Diseases Journal. Dec 2009; 28(12): 10521056.

Vaginal Microflora and Sepsis

It is estimated that 30-40% of infections resulting in neonatal sepsis deaths are
transmitted at the time of childbirth and have early onset of symptoms
This can be due to the vagina microflora, if a mother is known to have vaginosis she
may be treated with antibiotics
Even if a mother does not have vaginosis standard care to treat newborns eyes with
topical erythromycin or a similar antibiotic to prevent bacterial infection, showing
that the mothers flora may cause infection in infants
Group B streptococcus, part of the normal vaginal flora in about 25% of women, is a
leading cause of neonatal sepsis, mothers ideally should be treated with antibiotics
at 35-37 weeks of gestation if this is the case
If a baby is premature, antibiotics may have not already been administered
Other bacterial species may be transmitted from the mother to child in vaginal birth
such as E.coli and Staphylococcal species, also responsible for causing sepsis
GBS,Escherichia. coli,Haemophilus influenzae, andListeria monocytogenesand are
most likely to have been acquired transplacentally, by ascending or intrapartum
infection

Vaginal Vs Caesarean Births

GBS risk is reduced when a C-section is planned, no antibiotics are required
The risk is still high in an emergency C-section if the mothers waters have already
broken
Infectious outcomes among 497 women, who were undergoing elective repeat
cesarean delivery and 492 who attempted vaginal birth after cesarean (VBAC).
Rates of both suspected and confirmed neonatal sepsis were significantly lower in the
elective repeat cesarean group (2% versus 5%, P<0.05 for suspected sepsis, and 0%
versus 1% P<0.05 for proven sepsis
Although sepsis rates for the child are reduced, sepsis rates for the mother may
increase
The reduction of contact to the vaginal flora is most likely the main reason for a
reduced neonate sepsis rate in elective C-section

Neonatal Sepsis in developing

countries

99% of the approximate 1 million annual neonatal

deaths happen developing countries, at least 50%
of which are from home births or community
settings.

Access to appropriately-trained health workers

and high-quality services is limited.
Current recommendations of hospitalization and
parenteral therapy for managing neonatal
infections are inadequate.

Potential sociocultural issues can be a factor.

Likelihood of infection is increased due to other additional risk factors.

Under-recognition of illness, delay in care seeking

at the household level, and lack of access to both
appropriately trained health workers and to high
quality services to manage neonatal sepsis.
Late onset sepsis is complicated by a higher
percentage of Gram-negative bacteria and greater
antimicrobial resistance among the organisms.

Evidence shows newborns in developing countries often dont receive required

healthcare which contributes to the increased mortality in neonates and that this
is associated with an increase in mortality.

Unsafe birthing practices are common in developing countries which increase

the risk of neonatal sepsis.
Health education is a possible preventative intervention for improving neonatal
health.
Issues with the supply and quality of antimicrobials in certain developing areas.

Risk of neonate in Britain becoming

infected with Group B Streptococcus
1 in 1,000 when the mother is not known to be a carrier.
1 in 400 when the mother is known to be carrying Group B Streptococcus during pregnancy.
1 in 300 when the mother is carrying the bacteria during delivery.
1 in 100 when the mother has previously had a baby infected with Group B Streptococcus.
If the mother is known to have Group B Streptococcus bacteria and is given the antibiotics then the
risk to the baby is reduced significantly:
1 in 8,000 when the mother is known to be carrying GBS during pregnancy.
1 in 6,000 when the mother is carrying GBS during delivery.
1 in 2,000 when the mother has previously had a baby infected with GBS.
Preterm neonates are 3-15 times more likely to die from GBS infection. 83% of deaths from sepsis
are neonates born preterm.

Summary
1. Sepsis is a condition arising from a proven infection alongside SIRS
2. From history, much of the knowledge gained about sespsis was based on
cases of sepsis in pregnant women Childbirth was a large risk for sepsis
and death.
3. Studies are still underway however it seems neonatal sepsis is at a lower
rate when birth occurs via C-Sections due to decreased contact with the
mothers flora
4. Group B streptococci are a major cause of early onset sepsis but through
the use of intrapartum antibiotic prophylaxis, incidence has significantly
decreased.

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