Anemia of Prematurity - Portal Neonatal

• Head ultrasonograms in neonates with meningitis show evidence of ventriculitis, abnormal
parenchymal echogenicities, extracellular fluid, and chronic changes. Serially, head
ultrasonograms can demonstrate the progression of complications.
Procedures: Lumbar puncture is warranted for early- and late-onset sepsis, although clinicians may
be unsuccessful in obtaining sufficient or clear fluid for all the studies. Infants may be positioned on
their side or sitting with support, but adequate restraint is needed to avoid a traumatic tap. Because
the cord is lower in the spinal column in infants, the insertion site should be between L3 and L4. If
positive cultures are demonstrated, a follow-up lumbar puncture is often performed within 24-36
hours after antibiotic therapy to document CSF sterility. If organisms are still present, modification of
drug type or dosage may be required to adequately treat the meningitis. An additional lumbar
puncture within 24-36 hours is necessary if organisms are still present.
TREATMENT Section 6 of 11
Medical Care: Initiate treatment immediately because of the neonate's immunologic weaknesses for
fighting infection. Begin antibiotics as soon as diagnostic tests are performed. Additional therapies
have been investigated for the treatment of neonatal sepsis; however, no unequivocal proof that
these treatments are beneficial exists. These additional therapies include granulocyte transfusion,
intravenous immune globulin (IVIG) replacement, exchange transfusion, and the use of recombinant
cytokines.
• In the United States and Canada, the most current approach to treat early-onset neonatal
sepsis syndrome includes combined IV aminoglycoside and penicillin antibiotic therapy. This
provides coverage for gram-positive organisms, especially GBS, and gram-negative bacteria,
such as E coli. The specific antibiotics to be used are chosen on the basis of maternal history
and prevalent trends of organism colonization in individual nurseries.
o If infection appears to be nosocomial, direct coverage at organisms implicated in
hospital-acquired infections, including S aureus, S epidermis, and Pseudomonas
species. Most strains of S aureus produce beta-lactamase, which makes them resistant
to penicillin G, ampicillin, carbenicillin, and ticarcillin. Vancomycin has been favored for
this coverage; however, concern exists that overuse of this drug may lead to
vancomycin-resistant organisms, thereby eliminating the best response to these resistant
organisms. Cephalosporins are attractive in the treatment of nosocomial infection
because of their lack of dose-related toxicity and adequate serum and CSF
concentration; however, resistance by gram-negative organisms has occurred with their
use. Do not use ceftriaxone in infants with hyperbilirubinemia because it displaces
bilirubin from serum albumen. Resistance and sensitivities for the organism are used to
indicate the most effective drug.
o Aminoglycosides and vancomycin are both ototoxic and nephrotoxic; have caution when
using them. Check the serum level after 48 hours of treatment to determine if levels are
above those required for a therapeutic effect. The dosage amount or interval may need
to be changed to ensure adequate but nontoxic coverage. A serum level may be
warranted when the infant's clinical condition has not improved to ensure that a
therapeutic level has been reached. In addition, perform renal function and hearing
screening to determine any short- or long-range toxic effects of these drugs.
o If cultures are negative but the infant has significant risk for sepsis and/or clinical signs,
the clinician must decide whether to provide continued treatment. Three days of negative
cultures should provide confidence in the data; however, a small number of infants with
proven sepsis at postmortem had negative cultures during their initial sepsis workup.
Management is further complicated if the mother received antibiotic therapy before
delivery, especially close to delivery. This may result in negative cultures in the infant
who is still ill. Review all diagnostic data, including cultures, maternal and intrapartal risk
factors, CSF results, the CBC and differential radiographs, and the clinical picture to
determine the need for continued therapy. Treatment for 7-10 days may be appropriate,
even if the infant has negative cultures at 48 hours.