General approach to managing early onset sepsis or septic shock in neonates

Seek expert advice for the management of neonates with confirmed sepsis or microbiologically proven infection.

For advice on recognising sepsis and septic shock, see Identifying sepsis or septic shock.

Follow local sepsis and septic shock protocols, if available. In the absence of local protocols, the empirical regimens in this topic may be appropriate. These empirical regimens are intended for initial therapy only (up to 48 hours).

Consider the birthing parent’s (eg mother’s) clinical factors and microbiology results, including:

chorioamnionitis
colonisation with Streptococcus agalactiae (group B streptococcus)
active genital herpes simplex virus (HSV) infection
known infection or colonisation with multidrug-resistant gram-negative bacteria or methicillin-resistant Staphylococcus aureus (MRSA)
risk factors for infection with multidrug-resistant gram-negative bacteria or MRSA.

Modify therapy as soon as additional information is available (eg source of infection, results of Gram stain, culture and susceptibility testing). Evaluate the appropriateness of antimicrobial therapy daily, with consideration given to the neonate’s clinical status and the principles of antimicrobial stewardship Burston 2017.

Note: Empirical regimens are intended for initial therapy only (up to 48 hours) – modify as soon as additional information is available.

The recommendations in this topic apply to:

term neonates (gestational age 37 weeks or older) and preterm neonates (gestational age younger than 37 weeks) with early onset sepsis or septic shock (occurring within 72 hours of birth)
term and preterm neonates whose birthing parent has confirmed intra-amniotic infection, if presumptive therapy is indicated.

Antimicrobial choice depends on illness severity and whether meningitis has been excluded (usually by lumbar puncture). For empirical regimens for early onset sepsis or septic shock of unknown source in neonates, see:

Add-on therapy for HSV encephalitis is required for neonates suspected to have HSV infection, or whose birthing parent had active genital HSV infection at birth.

Although amoxicillin and ampicillin have traditionally been preferred to benzylpenicillin because of a theoretical advantage for sepsis caused by gram-negative pathogens (such as Escherichia coli), no difference has been observed in clinical outcomes. Benzylpenicillin is preferred for its narrower spectrum of activity.