Overview
Definition:
Late-onset sepsis (LOS) in the Neonatal Intensive Care Unit (NICU) is defined as a bloodstream infection occurring after 72 hours of life, typically presenting after the first week
Central line-associated bloodstream infections (CLABSIs) are a significant subset of LOS, directly linked to the use of indwelling vascular catheters.
Epidemiology:
CLABSIs are a leading cause of nosocomial infections in NICUs, contributing significantly to morbidity and mortality
Incidence rates vary but can range from 2-10 per 1000 central line days
Prematurity, low birth weight, prolonged hospitalization, and immunocompromise are key risk factors
Gram-positive bacteria (e.g., Staphylococcus epidermidis, Staphylococcus aureus) are most common, followed by Gram-negative organisms (e.g., Klebsiella, Pseudomonas) and Candida species.
Clinical Significance:
CLABSIs in neonates lead to increased length of stay, higher healthcare costs, prolonged antibiotic use, and a substantial risk of mortality
Early recognition and aggressive management, coupled with stringent preventive measures via care bundles, are paramount for improving outcomes and reducing the burden of these infections in vulnerable neonatal populations.
Clinical Presentation
Symptoms:
Non-specific signs are common
Lethargy
Poor feeding or feeding intolerance
Vomiting
Irritability or hypotonia
Temperature instability (hypothermia or fever)
Tachypnea or apnea
Bradycardia or tachycardia
Jaundice
Poor perfusion or hypotension
Hypoglycemia or hyperglycemia
Signs of organ dysfunction (e.g., decreased urine output).
Signs:
Vital sign abnormalities: Increased heart rate, respiratory rate, decreased blood pressure, temperature fluctuations
Signs of poor perfusion: Mottled skin, prolonged capillary refill time, decreased urine output
Abdominal distension
Bulging fontanelle
Rash or petechiae
Local signs at the catheter site (erythema, purulence) may be absent in neonates.
Diagnostic Criteria:
Neonatal clinical criteria often include at least one of the following: positive blood culture (with a single organism in a concentration generally considered diagnostic or multiple organisms), positive catheter tip culture, or clinical signs and symptoms of infection in conjunction with a positive laboratory test for a recognized pathogen from another sterile site (e.g., CSF, urine)
The CDC definition for CLABSI is also applicable.
Diagnostic Approach
History Taking:
Detailed history of prematurity, birth weight, gestational age, duration of central line use, type of catheter, site care protocols followed, maternal infections, and antibiotic exposure
Recent clinical changes in feeding, activity, and vital signs.
Physical Examination:
Comprehensive neonatal assessment focusing on vital signs, cardiorespiratory status, neurological status, abdominal examination (distension, bowel sounds), skin for rashes or signs of poor perfusion, and careful inspection of the central line insertion site
Assess for signs of end-organ damage.
Investigations:
Blood cultures: Crucial for identifying the causative pathogen
At least two sets from peripheral sites, and ideally, one from the central line
Concurrent urine culture and cerebrospinal fluid (CSF) analysis (if meningitis suspected)
Complete blood count (CBC) with differential: Leukocytosis or leukopenia, increased immature-to-total neutrophil ratio (I:T ratio), thrombocytopenia
Inflammatory markers: C-reactive protein (CRP), procalcitonin
Other investigations based on suspected organ involvement: Chest X-ray, urinalysis, liver function tests, renal function tests, coagulation profile.
Differential Diagnosis:
Other causes of non-specific neonatal distress: Hypoxic-ischemic encephalopathy, necrotizing enterocolitis, surgical emergencies (e.g., intestinal obstruction), metabolic derangements, intra-uterine infection (though typically presents earlier), viral infections.
Management
Initial Management:
Immediate hemodynamic support: Fluid resuscitation (e.g., normal saline, 10-20 mL/kg boluses)
Vasopressors if hypotension persists (e.g., dopamine, norepinephrine)
Adequate oxygenation and ventilation
Management of hypoglycemia, hypothermia, and coagulopathy
Consider removal or changing the central line if feasible and indicated.
Medical Management:
Empirical broad-spectrum antibiotic therapy: Choice depends on local resistance patterns, patient risk factors, and suspected pathogens
Common initial regimens include vancomycin (for Gram-positives, including MRSA) and a broad-spectrum cephalosporin or penicillin/beta-lactamase inhibitor (for Gram-negatives)
Duration of therapy typically 7-14 days or longer depending on pathogen and clinical response
Antifungal therapy (e.g., fluconazole) if Candida is suspected or confirmed
Tailor antibiotic therapy based on culture and sensitivity results
Antibiotic dosing in neonates requires careful consideration of gestational and postnatal age, renal function, and drug pharmacokinetics.
Surgical Management:
Rarely indicated for sepsis itself
May be considered for complications such as abscess formation, empyema, or cholecystitis related to infection
Removal or exchange of the central line is a critical interventional step often performed by nursing staff or physicians.
Supportive Care:
Close monitoring of vital signs, fluid balance, and laboratory parameters
Nutritional support: Maintain enteral feeds if tolerated
consider parenteral nutrition if necessary
Respiratory support as needed
Management of fever or hypothermia
Family support and communication.
Central Line Care Bundle
Hand Hygiene:
Strict adherence to hand washing before and after any contact with the patient or line
Use of alcohol-based hand rubs when hands are not visibly soiled.
Line Insertion Technique:
Maximal sterile barrier precautions during insertion (cap, mask, sterile gown, sterile gloves)
Use of chlorhexidine skin preparation
Avoidance of femoral vein cannulation when possible
Use of ultrasound guidance to minimize complications.
Line Maintenance And Assessment:
Daily review of the line necessity
Securement of the line to prevent dislodgement
Proper dressing changes using sterile technique and chlorhexidine
Regular assessment for signs of infection.
Line Discontinuation:
Prompt removal of the line when no longer medically indicated
Proper care of the insertion site after removal
Prompt notification of suspected infection.
Performance Monitoring:
Regular auditing of adherence to bundle components
Feedback to staff
Data collection on CLABSI rates and intervention effectiveness
Continuous quality improvement initiatives.
Prevention Strategies
Adherence To Bundles:
The cornerstone of prevention is rigorous and consistent implementation of the central line care bundle components
Staff education and competency validation are crucial.
Minimizing Line Duration:
Proactive planning for early line removal when indications are no longer present
Strategies to transition to peripheral IV access or oral medications as soon as possible.
Antimicrobial Stewardship:
Judicious use of antibiotics, timely de-escalation based on culture data, and adherence to institutional antibiotic guidelines to reduce selection pressure for resistant organisms.
Environmental Hygiene:
Maintaining a clean and safe NICU environment
Strict adherence to isolation precautions for infected or colonized neonates.
Key Points
Exam Focus:
DNB/NEET SS candidates must understand the definition, common pathogens, risk factors, clinical presentation of LOS and CLABSI, the principles of diagnosis, and crucially, the components of a central line care bundle and their importance in prevention.
Clinical Pearls:
Always consider a CLABSI in any neonate with unexplained clinical deterioration, even without local signs at the catheter site
The care bundle is a multi-faceted approach
non-compliance with even one component can significantly increase risk
Timely removal of the central line is as important as proper insertion and maintenance.
Common Mistakes:
Delayed recognition of sepsis due to non-specific symptoms
Inadequate or delayed empirical antibiotic therapy
Failure to perform timely blood cultures
Non-adherence to sterile techniques during line care
Not actively reviewing the need for ongoing central line use daily.