Progression from sepsis to septic shock and time to treatments in preterm infants with late‐onset sepsis

Abstract

Aim: Late-onset sepsis (LOS) in preterm infants can progress rapidly from minimal clinical signs and symptoms to septic shock which is associated with high mortality. The aim of this study was to describe the progression from sepsis to septic shock and evaluate our management performance with emphasis on time to treatments. Methods: This was a retrospective observational study including preterm infants ≤32 weeks gestation with LOS and septic shock defined as the requirement of fluids and vasopressors. Physiological changes and time to first diagnostics and treatments were determined from the point of first appearance of clinical signs and symptoms of sepsis (T ONSET ). Results: During the 10-year observational period, 279 infants developed LOS and 25 (8.9%) progressed to septic shock. The median (interquartile range) time from T ONSET to blood culture, administering antibiotics, fluid bolus and vasopressors was 8.4 (4.8-12.2), 9.2 (5.6-12.4), 14.6 (9.5-34.5) and 22.0 (14.6-44.7) h, respectively. Hypotension and raised lactate were prominent physiological changes in the progression to septic shock. Fluid bolus and vasopressors were administered when blood pressure was 20 and 41% below to what was normal before the infant became unwell. Vasopressors significantly increased blood pressure and heart rate. Mortality rate was 40% with no difference in time to treatments between survivors and non-survivors. Conclusion: Clinical recognition of the onset of sepsis in preterm infants remains difficult and contributes to delay of treatment. Once recognised, early administration of antibiotics, fluid bolus and vasopressors should be prioritised.

Clinical and haemodynamic characteristics of preterm infants with early onset sepsis

“…Various observational studies have assessed the haemodynamic response to LOS but few provided descriptive evidence of the haemodynamic presentation, clinical course of EOS and the progression to septic shock in this vulnerable age group 5–10,13–15 . Our clinical and ultrasound observational data revealed that preterm infants with EOS presented with either normal clinical findings and haemodynamic cardiac ultrasound parameters within the reference range, or with hypotension and higher as expected blood flows suggestive of warm shock.…”

“…In our cohort, 59% of preterm infants with EOS progressed from sepsis to septic shock and this was associated with a significant increase in mortality. Considering the high mortality and the difficulty in diagnosing EOS clinically, one could argue that all preterm infants with risk factors for EOS should undergo routine assessment of vasodilatory changes, either with cardiac ultrasound or with alternative methods such as near‐red infrared spectroscopy 7,8,20 . A major advantage of an early cardiac ultrasound would be to identify signs of vasodilatory shock as soon as it develops.…”

“…Considering the high mortality and the difficulty in diagnosing EOS clinically, one could argue that all preterm infants with risk factors for EOS should undergo routine assessment of vasodilatory changes, either with cardiac ultrasound or with alternative methods such as near‐red infrared spectroscopy. 7 , 8 , 20 A major advantage of an early cardiac ultrasound would be to identify signs of vasodilatory shock as soon as it develops. Early detection would facilitate important, timely interventions such as insertion of arterial lines, central venous access, judicious fluid management and early use of vasopressors.…”

“…There is limited data on the clinical and haemodynamic presentation of EOS in newborns, especially for preterm infants 5,6 . In studies of preterm neonates with late‐onset sepsis (LOS), the predominant haemodynamic presentation was high cardiac output and low systemic vascular resistance 7,8 . Our hypothesis was that preterm infants with EOS would behave similarly.…”

“…5,6 In studies of preterm neonates with late-onset sepsis (LOS), the predominant haemodynamic presentation was high cardiac output and low systemic vascular resistance. 7,8 Our hypothesis was that preterm infants with EOS would behave similarly. Our aim in this retrospective observational study was to describe the clinical and haemodynamic characteristics of preterm infants with EOS.…”