2 Early-Onset Neonatal Sepsis in a TermNeonate

The pediatric team is called to the vaginal delivery of a 31-year-old gravida 3, para 2-0-1-2 mother at 40 weeks and 1 day of gestation because of a category II tracing. The pregnancy is uncomplicated, including a negative group B Streptococcus test result, and clear amniotic fluid after artificial rupture of membranes 4.5 hours before delivery. Nuchal cord 1 is noted at the delivery of a female infant with 1and 5-minute Apgar scores of 8 and 9. Examination reveals a birthweight of 3,625 g, caput over the left occiput without bruising, generalized edema and bruising of the frontal scalp (Fig 1A). The infant exhibits discomfort with care. She is neurologically normal and breastfeeds well. Phototherapy is begun for a total bilirubin of 8.7 mg/dL (148.77 mmol/L) 25 hours after birth. On day 2 after birth, she becomes more irritable and less active, with mildly decreased tone and a weak cry. A sepsis evaluation is performed, and treatment is started with ampicillin and gentamicin. The initial white blood cell count is 33,000/mL (3 109/L) with an absolute neutrophil count of 1,000/mL (1 109/L), and no bands. Blood culture is positive for Escherichia coli at 8 hours on polymerase chain reaction (PCR)–based blood culture identification panel. Cerebrospinal fluid (CSF) is clear, with glucose of 76 mg/dL (4.22 mmol/L), protein 71 mg/dL (0.71 g/L), white blood cells 10/mL (10/10-6L), and red blood cell count of 0. Gram stain and PCR-based meningitis/encephalitis panel are negative. Antibiotic therapy is broadened to include ceftazidime, and the neonate is transferred to the NICU. Upon arrival in the NICU, the neonate is well appearing and alert. The anterior fontanelle is soft and flat, the scalp has scattered bruising, diffuse edema, and a 3.0 3.0–cm triangular dark crusted macule slightly and uniformly depressed on the right posterior occiput (Fig 1B). A complete review of the obstetrics records reveals delivery in occiput posterior position and application of fetal scalp electrodes (FSE). Blood culture from day 2 after birth confirms pan-susceptible E coli. Repeat blood culture and CSF and urine culture remain sterile. On day 4 after birth, the absolute neutrophil count is 4,900/mL (4.9 109/L) and the C-reactive protein (CRP) reaches 31.3 mg/dL (313 mg/L). Antibiotic treatment continues with ampicillin monotherapy. 2 Early-Onset Neonatal Sepsis in a Term Neonate