The use of CRP in Neonatal Early

Onset Sepsis: Experience of a Tertiary

Neonatal Unit in the UK

N Ganjoo, S Ali, M Ayeni

Introduction of NICE guidance (2012)

Neonatal infection (early onset): antibiotics for

prevention and treatment

• 1 Amber flag - observations

• 1 Red flag or 2 Amber flags – perform blood

culture and CRP and start antibiotics

EOS Risk Factors Risk Factors Tick Clinical Signs Tick

Invasive GBS in previous baby. Altered behaviour or responsiveness

Maternal GBS colonisation, bacteriuria

or infection in current pregnancy

Altered muscle tone (e.g. floppiness)

Rupture of membranes in a preterm infant of any duration prior to

the onset

of active labour

or

Rupture of membranes in a term infant more than 24 hours prior to

the onset of

active labour

Feeding difficulties

Feeding intolerance (e.g. vomiting, abdominal distension)

Signs of respiratory distress

Respiratory distress starting

more than 4 hours after birth

Preterm birth following spontaneous

labour (before 37 weeks gestation)

Hypoxia

Suspected or confirmed rupture of membranes more than 18hours

in pre-term birth

Jaundice within 24 hours after birth

Apnoea

Intrapartum fever higher than 38°C or confirmed or suspected

chorioamnionitis

Signs of neonatal encephalopathy.

Parenteral antibiotic treatment given to the woman for

confirmed or suspected invasive bacterial infection (such as

septicaemia) at any time during labour, or in the 24-hour

periods before and after the birth [This does not refer to

intrapartum antibiotic prophylaxis]

Seizures

Need for CPR.

Need for mechanical ventilation in a preterm baby.

Need for mechanical ventilation in a term baby.

Suspected or confirmed infection in another baby in the case of

a

multiple pregnancy

Persistent fetal circulation Temperature instability

(less than 36°C or more than 38°C) not environmental

Signs of shock

Abnormal coagulation.or thrombocytopenia

Oliguria persisting beyond 24 hours

after birth

Hypoglycaemia or hyperglycaemia.

Metabolic acidosis (≥-10mmol/L).

LP

• If strong clinical suspicion of infection

• Clinical symptoms or signs suggesting meningitis

• Consider performing an LP in those who did not have

an LP at presentation if

• CRP≥10mg/l or

• Have a positive blood culture or

• In those not responding satisfactorily to antibiotic treatment

• L&D use first CRP≥20mg/l or second CRP≥50mg/l as guide for

LP

Local Experience: Review

• Total episodes 169.

• 77 Female and 92 male.

• 129 Term and 40 Preterm.

• Gestation between 25+6 to 40+

weeks.

Local experience

0

10

20

30

40

50

60

70 64

15

0 9

0 5 5 4

2 2

26 2 10 15

0 7

1 0 0 0 0 4

Indication for Septic screen

Term Preterm

Local experience

Local experience: LP

Total 23/169 (13.5%) met our criteria for LP ( NICE 53/169- 31%)

• 2 failed attempts and 1 unstable baby-not performed.

• 7/23 LP’s where first CRP >20.

• 13/23 where first CRP <20 and 2nd CRP >50.

Local experience

0

96

5 2

34

6 1 1 1 3 4 2 3 4

0 0 0

20

40

60

80

100

120

1 day 2 days 3days 4days 5days 7days 10days 14days

Duration of Antibiotics

Term babies Preterm babies

Local experience

2

1

4

1

2

1

2

1

Indication for readmission to Paediatrics (Total 15)

Bronchiolitis Abdo distension+temp Apnoeas Shunt infection

Vomiting UTI Poor feeding/floppy Unknown

Readmission

15 representations to Hospital.

• Day of life representation: 8-83days.

• 12/15 presentations within 28days of

life.

• Day 11 life: Blood culture- 1 positive

ESBL E.Coli-, CRP 148-

vomiting+grunting,LP normal.

• LP: 3 performed and normal, no

growth.

Local experience Readmssn day of life, Indication

Indication for NICU admission

NICU CRP,Days of TX CRP, Days of Tx

D15,Bronchiolitis Sibling with GBS Normal, 2 days Normal, 2 days

D21,abdo disten Resp distress Normal, 2days Normal, 2 days

D8,apnoea Prem,resp distress Normal, 2days Normal, 2days

D28,apnoea Prem,resp distress Normal, 2days Normal, 2days

D11, vomiting/PS Mat pyrexia+Tx Raised,5days Normal, transferred

D11,ESBL E.Coli Focal seizure, paeds Raised, ?days-paed Raised, 14days

D15,Tachypnoea Tachypnoea Normal, 2days Normal, 2days

Not treated 4 babies

Other Normal, 2days Normal, no Treatment

D29,Bronchiolitis Tachypnoea Raised, 5days Abnormal, 7days

Conclusions

It is safe to follow our NICU criteria for-

a) identifying at risk neonates and

b) raising the CRP’s limits for otherwise well neonates

without adversely impacting the outcomes for the neonates treated.

Thank You.