Neonatal Sepsis in the Emergency Department
Daniel T. Robinson, MD, Praveen Kumar, MBBS, DCH, MD, FAAP,
Sandra B. Cadichon, MD
Despite significant improvements in the care and management of acutely ill infants,
septicemia remains one of the top 10 causes of neonatal death. Neonates can present
either shortly after birth or later with subtle signs to suggest infection. Early diagnosis and
prompt intervention are essential to prevent serious morbidity and mortality in neonates
(<28 days of age) and infants (>28 days of age) with sepsis. Unlike older children, a young
infant is often incapable of demonstrating clinical evidence of illness, and even a well-
appearing infant may have a bacterial or viral disease. The immaturity of the newborn’s
immune system may increase the susceptibility of these patients to infections. The
following article is a review of the clinical presentation, differential diagnosis, and
evaluation and management of a neonate presenting to the emergency department with
Clin Ped Emerg Med 9:160-168 C 2008 Elsevier Inc. All rights reserved.
KEYWORDS neonatal sepsis, bacterial and viral infection, emergency department, immune
epsis is ranked as the sixth leading cause of death
among neonates and the eighth leading cause of death
for infants through the first year of life . The incidence
of neonatal sepsis is 1 to 5 per 1000 live births . These
vulnerable patients present to the emergency department
(ED) or their primary care provider's office with non-
specific symptoms and are unable to articulate their
concerns. Quite often, the only presenting symptom is
fever, and not uncommonly, these infants are described as
Neonatal sepsis is classified as either early or late based
on the timing of presentation. In the literature, however,
there is no definitive consensus as to what age limits apply,
with early-onset sepsis ranging from 48 hours to 6 days
after delivery ; late-onset sepsis generally occurs beyond
the first week of life. The clinical relevance of this
distinction is that early-onset disease is often due to
organisms acquired during delivery. Late-onset disease is
only occasionally a result of vertical transmission and is
more frequently caused by organisms acquired after
delivery (nosocomial or community sources) . Char-
acteristics of early and late neonatal sepsis are summarized
in Table 1.
Risk Factors and Pathogenesis
Although no significant sex difference has been reported, it
was noted as early as the 1960s that male infants had a
higher incidence of neonatal sepsis than females, which
may be related to X-linked immunoregulatory genes .
Early-onset sepsis occurs primarily via vertical transmis-
sion, and the most common risk factors are prolonged
rupture of membranes (>18 hours before delivery),
maternal fever (>100.5°C), chorioamnionitis, and preterm
birth (<37 weeks estimated gestational age). The infant can
either become colonized with bacteria during passage
through an infected or colonized birth canal or via the
Department of Pediatrics, Feinberg School of Medicine, Northwestern
University, Chicago, IL.
Division of Neonatology, Children's Memorial Hospital, and
Northwestern Memorial Hospital, Chicago, IL.
Reprint requests and correspondence: Sandra B. Cadichon, MD, Division
of Neonatology, Children's Memorial Hospital, 2300 Children's Plaza
Box 45, Chicago, IL 60614. (E-mails: daniel-robinson@northwestern.
edu, firstname.lastname@example.org, email@example.com)
1522-8401/$ - see front matter C 2008 Elsevier Inc. All rights reserved.