Morning Rounds \u00b7 Neonatal Sepsis<\/title>\n<link href=\"https:\/\/fonts.googleapis.com\/css2?family=Playfair+Display:ital,wght@0,400;0,600;0,700;1,400;1,600&family=Source+Serif+4:ital,wght@0,300;0,400;0,600;1,400&display=swap\" rel=\"stylesheet\">\n<style>\n#neo03 *,#neo03 *::before,#neo03 *::after{box-sizing:border-box;margin:0;padding:0}\n#neo03{\n --ter:#8B3A3A;\n --ter-light:#A85050;\n --ter-pale:#F9EDED;\n --ter-dark:#5C1E1E;\n --correct:#2D6B47;--correct-bg:#EAF6EF;--correct-border:#3A9960;\n --wrong:#B83232;--wrong-bg:#FDF0F0;--wrong-border:#E53935;\n --ink:#2A1010;--ink-mid:#5A3030;--ink-soft:#9A7070;\n --line:#EDD8D8;--cream:#FDF4F4;--warm:#FFFAFA;\n font-family:'Source Serif 4',Georgia,serif;\n font-size:16px;color:var(--ink);background:var(--cream);\n line-height:1.7;padding:0 0 64px;\n}\n#neo03 .mr-header{background:var(--ter);color:#FFFAFA;padding:34px 24px 28px;text-align:center}\n#neo03 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style=\"width:100%;max-width:580px;display:block;margin:0 auto\" aria-label=\"Early-onset vs late-onset neonatal sepsis comparison\">\n <rect width=\"580\" height=\"184\" rx=\"6\" fill=\"#FFFAFA\"\/>\n \n <rect x=\"8\" y=\"8\" width=\"168\" height=\"28\" rx=\"4\" fill=\"#E8C0C0\"\/>\n <rect x=\"186\" y=\"8\" width=\"186\" height=\"28\" rx=\"4\" fill=\"#8B3A3A\"\/>\n <rect x=\"382\" y=\"8\" width=\"190\" height=\"28\" rx=\"4\" fill=\"#5C1E1E\"\/>\n <text x=\"92\" y=\"27\" text-anchor=\"middle\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"11\" font-weight=\"700\" fill=\"#5C1E1E\">Feature<\/text>\n <text x=\"279\" y=\"27\" text-anchor=\"middle\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"11\" font-weight=\"700\" fill=\"#FFFAFA\">Early-Onset (EOS)<\/text>\n <text x=\"477\" y=\"27\" text-anchor=\"middle\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"11\" font-weight=\"700\" fill=\"#FFFAFA\">Late-Onset (LOS)<\/text>\n \n <rect x=\"0\" y=\"44\" width=\"580\" height=\"26\" fill=\"#FDF4F4\"\/>\n <rect x=\"0\" y=\"70\" width=\"580\" height=\"26\" fill=\"#FFFAFA\"\/>\n <rect x=\"0\" y=\"96\" width=\"580\" height=\"26\" fill=\"#FDF4F4\"\/>\n <rect x=\"0\" y=\"122\" width=\"580\" height=\"26\" fill=\"#FFFAFA\"\/>\n <rect x=\"0\" y=\"148\" width=\"580\" height=\"26\" fill=\"#FDF4F4\"\/>\n \n <text x=\"6\" y=\"62\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"9\" font-weight=\"700\" fill=\"#9A7070\">Age of onset<\/text>\n <text x=\"6\" y=\"88\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"9\" font-weight=\"700\" fill=\"#9A7070\">Source<\/text>\n <text x=\"6\" y=\"111\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"9\" font-weight=\"700\" fill=\"#9A7070\">Common organisms<\/text>\n <text x=\"6\" y=\"137\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"9\" font-weight=\"700\" fill=\"#9A7070\">Risk factors<\/text>\n <text x=\"6\" y=\"163\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"9\" font-weight=\"700\" fill=\"#9A7070\">Empirical Rx<\/text>\n \n <text x=\"279\" y=\"62\" text-anchor=\"middle\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"10\" fill=\"#2A1010\">< 72 hours of life<\/text>\n <text x=\"279\" y=\"88\" text-anchor=\"middle\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"10\" fill=\"#2A1010\">Vertical (maternal)<\/text>\n <text x=\"279\" y=\"107\" text-anchor=\"middle\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"10\" fill=\"#2A1010\">GBS, E. coli,<\/text>\n <text x=\"279\" y=\"119\" text-anchor=\"middle\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"10\" fill=\"#2A1010\">Listeria monocytogenes<\/text>\n <text x=\"279\" y=\"133\" text-anchor=\"middle\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"10\" fill=\"#2A1010\">PROM, maternal GBS,<\/text>\n <text x=\"279\" y=\"145\" text-anchor=\"middle\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"10\" fill=\"#2A1010\">prematurity, fever<\/text>\n <text x=\"279\" y=\"163\" text-anchor=\"middle\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"10\" fill=\"#2A1010\">Benzylpenicillin + gentamicin<\/text>\n \n <text x=\"477\" y=\"62\" text-anchor=\"middle\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"10\" fill=\"#2A1010\">> 72 h (up to 28 days)<\/text>\n <text x=\"477\" y=\"88\" text-anchor=\"middle\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"10\" fill=\"#2A1010\">Horizontal (nosocomial)<\/text>\n <text x=\"477\" y=\"107\" text-anchor=\"middle\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"10\" fill=\"#2A1010\">CoNS, Staph. aureus,<\/text>\n <text x=\"477\" y=\"119\" text-anchor=\"middle\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"10\" fill=\"#2A1010\">Klebsiella, Candida<\/text>\n <text x=\"477\" y=\"133\" text-anchor=\"middle\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"10\" fill=\"#2A1010\">Prematurity, central lines,<\/text>\n <text x=\"477\" y=\"145\" text-anchor=\"middle\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"10\" fill=\"#2A1010\">prolonged TPN, intubation<\/text>\n <text x=\"477\" y=\"163\" text-anchor=\"middle\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"10\" fill=\"#2A1010\">Vancomycin + gentamicin<\/text>\n \n <line x1=\"176\" y1=\"8\" x2=\"176\" y2=\"184\" stroke=\"#EDD8D8\" stroke-width=\"1\"\/>\n <line x1=\"372\" y1=\"8\" x2=\"372\" y2=\"184\" stroke=\"#EDD8D8\" stroke-width=\"1\"\/>\n \n <line x1=\"0\" y1=\"44\" x2=\"580\" y2=\"44\" stroke=\"#EDD8D8\" stroke-width=\"0.5\"\/>\n <line x1=\"0\" y1=\"70\" x2=\"580\" y2=\"70\" stroke=\"#EDD8D8\" stroke-width=\"0.5\"\/>\n <line x1=\"0\" y1=\"96\" x2=\"580\" y2=\"96\" stroke=\"#EDD8D8\" stroke-width=\"0.5\"\/>\n <line x1=\"0\" y1=\"122\" x2=\"580\" y2=\"122\" stroke=\"#EDD8D8\" stroke-width=\"0.5\"\/>\n <line x1=\"0\" y1=\"148\" x2=\"580\" y2=\"148\" stroke=\"#EDD8D8\" stroke-width=\"0.5\"\/>\n <\/svg>\n <figcaption>\n <strong>EOS<\/strong> (<72 h): vertical transmission, GBS and gram-negatives, empirical benzylpenicillin + gentamicin.\n <strong>LOS<\/strong> (>72 h): nosocomial, CoNS and Staphylococcus aureus dominate, empirical vancomycin + gentamicin.\n In both: obtain blood culture <em>before<\/em> antibiotics, but never delay treatment pending the result.\n LP should be performed in all confirmed or probable sepsis cases unless the neonate is too unstable.\n <\/figcaption>\n <\/figure>\n<\/div>\n\n\n\n<div id=\"neo03\">\n\n <div class=\"mr-header\">\n <div class=\"mr-eyebrow\">Morning Rounds · Neonatology Series<\/div>\n <div class=\"mr-title\">\n Neonatal Sepsis<br><em>Clinical Reasoning<\/em>\n <\/div>\n <div class=\"mr-subtitle\">Five cases · Read carefully · Trust your instinct<\/div>\n <div class=\"mr-chips\">\n <span class=\"mr-chip\">5 Cases<\/span>\n <span class=\"mr-chip\">+4 \/ −1 scoring<\/span>\n <span class=\"mr-chip\">Options reshuffled<\/span>\n <\/div>\n <\/div>\n\n <div class=\"mr-sentinel\" id=\"neo03-sentinel\"><\/div>\n\n <div class=\"mr-progress\" id=\"neo03-progress\">\n <div class=\"mr-prog-inner\">\n <div class=\"mr-pips\" id=\"neo03-pips\"><\/div>\n <\/div>\n <\/div>\n\n <div class=\"mr-body\">\n <div id=\"neo03-cases\"><\/div>\n\n <div class=\"mr-submit-wrap\">\n <button class=\"mr-btn\" id=\"neo03-submit\">Submit for Debrief<\/button>\n <\/div>\n\n <div class=\"mr-score\" id=\"neo03-score\">\n <div class=\"mr-score-in\">\n <div class=\"mr-score-ey\">Round Complete<\/div>\n <div class=\"mr-ring\" id=\"neo03-ring\">\n <div class=\"mr-ring-in\">\n <span class=\"mr-ring-pct\" id=\"neo03-pct\">0%<\/span>\n <span class=\"mr-ring-sub\">net<\/span>\n <\/div>\n <\/div>\n <div class=\"mr-score-title\">Your Debrief<\/div>\n <div class=\"mr-score-net\" id=\"neo03-net\"><\/div>\n <div class=\"mr-verdict\" id=\"neo03-verdict\"><\/div>\n <div class=\"mr-bands\">\n <span class=\"mr-band mr-band-c\" id=\"neo03-ct-c\"><\/span>\n <span class=\"mr-band mr-band-w\" id=\"neo03-ct-w\"><\/span>\n <span class=\"mr-band mr-band-s\" id=\"neo03-ct-s\"><\/span>\n <\/div>\n <button class=\"mr-retry\" id=\"neo03-retry\">↻ New Round<\/button>\n <\/div>\n <\/div>\n\n <\/div>\n<\/div>\n\n\n<script>\n(function () {\n 'use strict';\n\n var NS = 'neo03';\n var TOTAL = 5;\n var MAX = 20;\n var LTRS = ['A','B','C','D'];\n\n var QS = [\n\n {\n id: 1,\n tag: 'Early-Onset Neonatal Sepsis — Antibiotic Choice',\n stem: 'A <strong>term neonate (38 weeks)<\/strong> born by normal vaginal delivery develops <strong>temperature instability, poor feeding, and respiratory distress at 18 hours of life<\/strong>. The mother had prolonged rupture of membranes for 24 hours and untreated <em>Group B Streptococcus (GBS)<\/em> colonisation detected at 36 weeks. WBC is 3,400\/mm³ (neutropenia), CRP is 32 mg\/L, blood culture is pending. What is the correct immediate antibiotic regimen?',\n correct: 'Intravenous benzylpenicillin plus gentamicin — narrow-spectrum cover for GBS with synergistic gram-negative activity',\n opts: [\n 'Intravenous benzylpenicillin plus gentamicin — narrow-spectrum cover for GBS with synergistic gram-negative activity',\n 'Oral amoxicillin alone — early-onset GBS sepsis in term neonates responds to oral beta-lactams',\n 'Intravenous vancomycin plus cefotaxime — required because GBS has intrinsic penicillin resistance',\n 'Withhold antibiotics until blood culture is positive — neutropenia in the first 24 hours is physiological'\n ],\n exp: '<strong>Early-onset neonatal sepsis (EOS)<\/strong> presents within <strong>72 hours<\/strong> of birth; the commonest organisms are <em>Group B Streptococcus<\/em> and gram-negative enteric bacilli (<em>E. coli<\/em>, <em>Klebsiella<\/em>). Risk factors here include maternal GBS colonisation, PROM >18 hours, and lack of intrapartum antibiotic prophylaxis. The empirical regimen of choice is <strong>IV benzylpenicillin<\/strong> (narrow-spectrum, highly effective against GBS) <strong>plus IV gentamicin<\/strong> (synergistic bactericidal cover against gram-negatives). GBS is <em>not<\/em> penicillin-resistant; vancomycin is not indicated. Blood culture must be obtained first, but <strong>treatment must not be delayed<\/strong> pending the result.',\n imgId: 'neo03-img1'\n },\n\n {\n id: 2,\n tag: 'Late-Onset Neonatal Sepsis — Organism & Source',\n stem: 'A <strong>26-week preterm male<\/strong> has been in the NICU for 18 days on total parenteral nutrition via a percutaneous central venous catheter (PICC line). He develops <strong>temperature instability, feed intolerance, apnoea, and a raised CRP<\/strong>. Blood culture grows a <strong>coagulase-negative Staphylococcus (CoNS)<\/strong>. The PICC line is still in situ. What is the most appropriate management?',\n correct: 'Start IV vancomycin and remove the PICC line — CoNS line-associated sepsis requires source control alongside antibiotics',\n opts: [\n 'Start IV vancomycin and remove the PICC line — CoNS line-associated sepsis requires source control alongside antibiotics',\n 'Start IV benzylpenicillin — CoNS is reliably penicillin-sensitive in neonates',\n 'Repeat the blood culture and withhold antibiotics — a single CoNS isolate always represents contamination',\n 'Start IV fluconazole — CoNS is a fungal pathogen requiring antifungal treatment'\n ],\n exp: '<strong>Late-onset sepsis (LOS)<\/strong> presents after 72 hours and is predominantly <strong>nosocomial<\/strong>. <strong>Coagulase-negative Staphylococci (CoNS)<\/strong> — especially <em>S. epidermidis<\/em> — are the single commonest cause of LOS in NICU, almost always associated with indwelling central venous catheters. CoNS forms biofilm on catheter surfaces and is typically <strong>methicillin-resistant<\/strong>, requiring <strong>vancomycin<\/strong>. A single blood culture isolate in a symptomatic neonate with a central line is <em>not<\/em> dismissed as contamination. <strong>Source control<\/strong> — removal of the PICC line — is essential alongside antibiotics; failure to remove the line leads to treatment failure and relapse.',\n imgId: null\n },\n\n {\n id: 3,\n tag: 'Neonatal Sepsis — Lumbar Puncture Decision',\n stem: 'A <strong>term neonate<\/strong> presents at 36 hours of life with <strong>seizures, bulging fontanelle, and high-pitched cry<\/strong>. Temperature is 38.8°C. WBC is 22,000\/mm³ with a left shift; CRP is 68 mg\/L. Blood culture has been sent. The team debates whether to perform a lumbar puncture before starting antibiotics. Which statement is MOST CORRECT?',\n correct: 'LP should be performed before antibiotics if the neonate is stable enough — meningitis cannot be excluded without CSF analysis and alters both treatment duration and choice',\n opts: [\n 'LP should be performed before antibiotics if the neonate is stable enough — meningitis cannot be excluded without CSF analysis and alters both treatment duration and choice',\n 'LP is contraindicated in neonates under 48 hours of age regardless of clinical signs',\n 'LP can safely be deferred for 72 hours as the CSF will remain interpretable after three days of IV antibiotics',\n 'A bulging fontanelle is a contraindication to LP due to risk of tentorial herniation in neonates'\n ],\n exp: '<strong>Neonatal meningitis<\/strong> occurs in up to 20–30% of bacteraemic neonates; blood culture alone cannot exclude it. CSF analysis is therefore <strong>mandatory in all neonates with confirmed or probable sepsis<\/strong> unless the baby is too haemodynamically unstable for the procedure. LP should ideally be performed <em>before<\/em> antibiotics because sterilisation of CSF can occur within hours, eliminating the ability to identify the organism and its sensitivity. Meningitis changes treatment: duration extends to 14–21 days (vs 7–10 days for sepsis alone) and some organisms (e.g. gram-negatives) require a third-generation cephalosporin added to the regimen. A bulging fontanelle reflects raised ICP but is <em>not<\/em> an absolute contraindication in a neonate — unlike in older children, tentorial herniation from LP is exceptionally rare.',\n imgId: null\n },\n\n {\n id: 4,\n tag: 'Neonatal Sepsis — Listeria monocytogenes',\n stem: 'A <strong>term neonate<\/strong> is born to a mother who consumed unpasteurised cheese at 37 weeks of pregnancy. The mother had a febrile illness with myalgia 2 weeks before delivery. The neonate is born with <strong>meconium-stained liquor at term, skin pustules, and hepatosplenomegaly<\/strong>. Blood culture grows a <strong>gram-positive bacillus<\/strong>. Which organism is most likely, and what is the critical antibiotic consideration?',\n correct: 'Listeria monocytogenes — it is intrinsically resistant to all cephalosporins; ampicillin plus gentamicin is required',\n opts: [\n 'Listeria monocytogenes — it is intrinsically resistant to all cephalosporins; ampicillin plus gentamicin is required',\n 'Group B Streptococcus — a gram-positive coccus sensitive to benzylpenicillin monotherapy',\n 'Staphylococcus aureus — treat with flucloxacillin; cephalosporins are first-line',\n 'Enterococcus faecalis — sensitive to vancomycin; cephalosporins provide adequate cover'\n ],\n exp: '<strong>Listeria monocytogenes<\/strong> is a gram-positive <em>bacillus<\/em> (not coccus) transmitted via contaminated food (soft cheeses, deli meats, smoked fish). Maternal infection causes a flu-like illness; fetal infection can cause preterm labour, meconium staining at term (unusual — an important clue), or early-onset neonatal sepsis with granulomatosis infantiseptica (skin pustules, hepatosplenomegaly). The critical pharmacology: <strong>Listeria is intrinsically resistant to ALL cephalosporins<\/strong>. Standard empirical regimens using cefotaxime or ceftriaxone will fail. Treatment is <strong>ampicillin (or amoxicillin) plus gentamicin<\/strong>. This is why benzylpenicillin + gentamicin (rather than a cephalosporin) is preferred for EOS — it covers Listeria; cephalosporins do not.',\n imgId: null\n },\n\n {\n id: 5,\n tag: 'Neonatal Candidiasis — Invasive Fungal Sepsis',\n stem: 'A <strong>24-week preterm female<\/strong>, now day 21 of life, has been on broad-spectrum antibiotics for 14 days for culture-negative suspected sepsis. She has a central line, is on TPN, and has received prolonged corticosteroids for BPD. She develops <strong>clinical deterioration with thrombocytopenia, hyperglycaemia, and a raised CRP<\/strong>. Blood culture grows <strong>Candida albicans<\/strong>. What is the correct management?',\n correct: 'Start IV amphotericin B or fluconazole, remove the central line, and perform ophthalmology review and echocardiography to exclude end-organ involvement',\n opts: [\n 'Start IV amphotericin B or fluconazole, remove the central line, and perform ophthalmology review and echocardiography to exclude end-organ involvement',\n 'Start oral nystatin alone — systemic candidiasis in neonates responds to topical antifungals',\n 'Continue current antibiotics and add metronidazole — Candida on blood culture represents gut colonisation, not true invasive infection',\n 'Fluconazole is contraindicated under 28 weeks corrected age; amphotericin B is the only option regardless of species sensitivity'\n ],\n exp: '<strong>Invasive candidiasis<\/strong> in VLBW\/ELBW neonates carries mortality up to 30%. Risk factors are classical here: extreme prematurity, prolonged broad-spectrum antibiotics, central line, TPN, and corticosteroids. <strong>Candida on blood culture is never dismissed<\/strong> as contamination in this setting. Management: (1) <strong>IV antifungal<\/strong> — fluconazole is first-line for susceptible <em>C. albicans<\/em>; liposomal amphotericin B for fluconazole-resistant species or renal impairment; (2) <strong>Remove the central line<\/strong> — source control is essential; (3) <strong>Ophthalmic review<\/strong> for Candida endophthalmitis; (4) <strong>Echocardiography<\/strong> to exclude endocarditis or intracardiac thrombus. Prophylactic oral fluconazole in ELBW neonates in high-incidence units is evidence-based and reduces invasive candidiasis.',\n imgId: null\n }\n\n ];\n\n\n var answers = {};\n var answered = 0;\n var shuffled = {};\n var done = false;\n\n function byId(id) { return document.getElementById(id); }\n function gid(suffix) { return byId(NS + '-' + suffix); }\n\n function shuffleArr(arr) {\n var a = arr.slice(), i, j, tmp;\n for (i = a.length - 1; i > 0; i--) {\n j = Math.floor(Math.random() * (i + 1));\n tmp = a[i]; a[i] = a[j]; a[j] = tmp;\n }\n return a;\n }\n\n function countVal(val) {\n var k, n = 0;\n for (k in answers) {\n if (answers.hasOwnProperty(k) && answers[k] === val) n++;\n }\n return n;\n }\n\n function buildPips() {\n var cont = gid('pips'), i, q, wLine, wPip, line, pip;\n cont.innerHTML = '';\n for (i = 0; i < QS.length; i++) {\n q = QS[i];\n if (i > 0) {\n wLine = document.createElement('div');\n wLine.className = 'mr-pip-wrap';\n line = document.createElement('div');\n line.className = 'mr-pip-line';\n line.id = NS + '-pl' + q.id;\n wLine.appendChild(line);\n cont.appendChild(wLine);\n }\n wPip = document.createElement('div');\n wPip.className = 'mr-pip-wrap';\n pip = document.createElement('div');\n pip.className = 'mr-pip';\n pip.id = NS + '-pip' + q.id;\n pip.textContent = String(q.id);\n wPip.appendChild(pip);\n cont.appendChild(wPip);\n }\n }\n\n function build() {\n var cont, i, q, opts, card, top, numDiv, meta, tag, stem,\n rule, optsDiv, expDiv, lbl, txt, imgDiv, imgSrc, j,\n optEl, ltrSpan, txtSpan;\n\n cont = gid('cases');\n cont.innerHTML = '';\n answers = {}; answered = 0; shuffled = {}; done = false;\n gid('score').style.display = 'none';\n buildPips();\n\n for (i = 0; i < QS.length; i++) {\n q = QS[i];\n opts = shuffleArr(q.opts);\n shuffled[q.id] = opts;\n\n card = document.createElement('div');\n card.className = 'mr-case';\n\n top = document.createElement('div');\n top.className = 'mr-case-top';\n\n numDiv = document.createElement('div');\n numDiv.className = 'mr-num';\n numDiv.textContent = q.id < 10 ? 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{"id":36983,"date":"2026-06-07T06:56:15","date_gmt":"2026-06-07T01:26:15","guid":{"rendered":"https:\/\/atsixty.com\/?p=36983"},"modified":"2026-06-07T06:56:58","modified_gmt":"2026-06-07T01:26:58","slug":"neonatal-sepsis","status":"publish","type":"post","link":"https:\/\/atsixty.com\/index.php\/clinical\/pediatrics\/neonatal-sepsis\/","title":{"rendered":"Neonatal Sepsis"},"content":{"rendered":"\n\n\n\n\n\n\n\n\nMorning Rounds \u00b7 Neonatal Sepsis<\/title>\n<link href=\"https:\/\/fonts.googleapis.com\/css2?family=Playfair+Display:ital,wght@0,400;0,600;0,700;1,400;1,600&family=Source+Serif+4:ital,wght@0,300;0,400;0,600;1,400&display=swap\" rel=\"stylesheet\">\n<style>\n#neo03 *,#neo03 *::before,#neo03 *::after{box-sizing:border-box;margin:0;padding:0}\n#neo03{\n --ter:#8B3A3A;\n --ter-light:#A85050;\n --ter-pale:#F9EDED;\n --ter-dark:#5C1E1E;\n --correct:#2D6B47;--correct-bg:#EAF6EF;--correct-border:#3A9960;\n --wrong:#B83232;--wrong-bg:#FDF0F0;--wrong-border:#E53935;\n 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.mr-retry:hover{background:var(--ter);color:#FFFAFA}\n@media(max-width:480px){#neo03 .mr-title{font-size:1.4rem}#neo03 .mr-num{font-size:1.7rem}#neo03 .mr-stem{font-size:0.9rem}#neo03 .mr-opt-text{font-size:0.86rem}}\n<\/style>\n\n\n\n<div id=\"neo03-img1\" style=\"display:none\">\n <figure class=\"mr-img-wrap\">\n <svg viewBox=\"0 0 580 184\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" style=\"width:100%;max-width:580px;display:block;margin:0 auto\" aria-label=\"Early-onset vs late-onset neonatal sepsis comparison\">\n <rect width=\"580\" height=\"184\" rx=\"6\" fill=\"#FFFAFA\"\/>\n \n <rect x=\"8\" y=\"8\" width=\"168\" height=\"28\" rx=\"4\" fill=\"#E8C0C0\"\/>\n <rect x=\"186\" y=\"8\" width=\"186\" height=\"28\" rx=\"4\" fill=\"#8B3A3A\"\/>\n <rect x=\"382\" y=\"8\" width=\"190\" height=\"28\" rx=\"4\" fill=\"#5C1E1E\"\/>\n <text x=\"92\" y=\"27\" text-anchor=\"middle\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"11\" font-weight=\"700\" fill=\"#5C1E1E\">Feature<\/text>\n <text x=\"279\" y=\"27\" text-anchor=\"middle\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"11\" font-weight=\"700\" fill=\"#FFFAFA\">Early-Onset (EOS)<\/text>\n <text x=\"477\" y=\"27\" text-anchor=\"middle\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"11\" font-weight=\"700\" fill=\"#FFFAFA\">Late-Onset (LOS)<\/text>\n \n <rect x=\"0\" y=\"44\" width=\"580\" height=\"26\" fill=\"#FDF4F4\"\/>\n <rect x=\"0\" y=\"70\" width=\"580\" height=\"26\" fill=\"#FFFAFA\"\/>\n <rect x=\"0\" y=\"96\" width=\"580\" height=\"26\" fill=\"#FDF4F4\"\/>\n <rect x=\"0\" y=\"122\" width=\"580\" height=\"26\" fill=\"#FFFAFA\"\/>\n <rect x=\"0\" y=\"148\" width=\"580\" height=\"26\" fill=\"#FDF4F4\"\/>\n \n <text x=\"6\" y=\"62\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"9\" font-weight=\"700\" fill=\"#9A7070\">Age of onset<\/text>\n <text x=\"6\" y=\"88\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"9\" font-weight=\"700\" fill=\"#9A7070\">Source<\/text>\n <text x=\"6\" y=\"111\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"9\" font-weight=\"700\" fill=\"#9A7070\">Common organisms<\/text>\n <text x=\"6\" y=\"137\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"9\" font-weight=\"700\" fill=\"#9A7070\">Risk factors<\/text>\n <text x=\"6\" y=\"163\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"9\" font-weight=\"700\" fill=\"#9A7070\">Empirical Rx<\/text>\n \n <text x=\"279\" y=\"62\" text-anchor=\"middle\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"10\" fill=\"#2A1010\">< 72 hours of life<\/text>\n <text x=\"279\" y=\"88\" text-anchor=\"middle\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"10\" fill=\"#2A1010\">Vertical (maternal)<\/text>\n <text x=\"279\" y=\"107\" text-anchor=\"middle\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"10\" fill=\"#2A1010\">GBS, E. coli,<\/text>\n <text x=\"279\" y=\"119\" text-anchor=\"middle\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"10\" fill=\"#2A1010\">Listeria monocytogenes<\/text>\n <text x=\"279\" y=\"133\" text-anchor=\"middle\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"10\" fill=\"#2A1010\">PROM, maternal GBS,<\/text>\n <text x=\"279\" y=\"145\" text-anchor=\"middle\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"10\" fill=\"#2A1010\">prematurity, fever<\/text>\n <text x=\"279\" y=\"163\" text-anchor=\"middle\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"10\" fill=\"#2A1010\">Benzylpenicillin + gentamicin<\/text>\n \n <text x=\"477\" y=\"62\" text-anchor=\"middle\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"10\" fill=\"#2A1010\">> 72 h (up to 28 days)<\/text>\n <text x=\"477\" y=\"88\" text-anchor=\"middle\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"10\" fill=\"#2A1010\">Horizontal (nosocomial)<\/text>\n <text x=\"477\" y=\"107\" text-anchor=\"middle\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"10\" fill=\"#2A1010\">CoNS, Staph. aureus,<\/text>\n <text x=\"477\" y=\"119\" text-anchor=\"middle\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"10\" fill=\"#2A1010\">Klebsiella, Candida<\/text>\n <text x=\"477\" y=\"133\" text-anchor=\"middle\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"10\" fill=\"#2A1010\">Prematurity, central lines,<\/text>\n <text x=\"477\" y=\"145\" text-anchor=\"middle\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"10\" fill=\"#2A1010\">prolonged TPN, intubation<\/text>\n <text x=\"477\" y=\"163\" text-anchor=\"middle\" font-family=\"Source Serif 4,Georgia,serif\" font-size=\"10\" fill=\"#2A1010\">Vancomycin + gentamicin<\/text>\n \n <line x1=\"176\" y1=\"8\" x2=\"176\" y2=\"184\" stroke=\"#EDD8D8\" stroke-width=\"1\"\/>\n <line x1=\"372\" y1=\"8\" x2=\"372\" y2=\"184\" stroke=\"#EDD8D8\" stroke-width=\"1\"\/>\n \n <line x1=\"0\" y1=\"44\" x2=\"580\" y2=\"44\" stroke=\"#EDD8D8\" stroke-width=\"0.5\"\/>\n <line x1=\"0\" y1=\"70\" x2=\"580\" y2=\"70\" stroke=\"#EDD8D8\" stroke-width=\"0.5\"\/>\n <line x1=\"0\" y1=\"96\" x2=\"580\" y2=\"96\" stroke=\"#EDD8D8\" stroke-width=\"0.5\"\/>\n <line x1=\"0\" y1=\"122\" x2=\"580\" y2=\"122\" stroke=\"#EDD8D8\" stroke-width=\"0.5\"\/>\n <line x1=\"0\" y1=\"148\" x2=\"580\" y2=\"148\" stroke=\"#EDD8D8\" stroke-width=\"0.5\"\/>\n <\/svg>\n <figcaption>\n <strong>EOS<\/strong> (<72 h): vertical transmission, GBS and gram-negatives, empirical benzylpenicillin + gentamicin.\n <strong>LOS<\/strong> (>72 h): nosocomial, CoNS and Staphylococcus aureus dominate, empirical vancomycin + gentamicin.\n In both: obtain blood culture <em>before<\/em> antibiotics, but never delay treatment pending the result.\n LP should be performed in all confirmed or probable sepsis cases unless the neonate is too unstable.\n <\/figcaption>\n <\/figure>\n<\/div>\n\n\n\n<div id=\"neo03\">\n\n <div class=\"mr-header\">\n <div class=\"mr-eyebrow\">Morning Rounds · Neonatology Series<\/div>\n <div class=\"mr-title\">\n Neonatal Sepsis<br><em>Clinical Reasoning<\/em>\n <\/div>\n <div class=\"mr-subtitle\">Five cases · Read carefully · Trust your instinct<\/div>\n <div class=\"mr-chips\">\n <span class=\"mr-chip\">5 Cases<\/span>\n <span class=\"mr-chip\">+4 \/ −1 scoring<\/span>\n <span class=\"mr-chip\">Options reshuffled<\/span>\n <\/div>\n <\/div>\n\n <div class=\"mr-sentinel\" id=\"neo03-sentinel\"><\/div>\n\n <div class=\"mr-progress\" id=\"neo03-progress\">\n <div class=\"mr-prog-inner\">\n <div class=\"mr-pips\" id=\"neo03-pips\"><\/div>\n <\/div>\n <\/div>\n\n <div class=\"mr-body\">\n <div id=\"neo03-cases\"><\/div>\n\n <div class=\"mr-submit-wrap\">\n <button class=\"mr-btn\" id=\"neo03-submit\">Submit for Debrief<\/button>\n <\/div>\n\n <div class=\"mr-score\" id=\"neo03-score\">\n <div class=\"mr-score-in\">\n <div class=\"mr-score-ey\">Round Complete<\/div>\n <div class=\"mr-ring\" id=\"neo03-ring\">\n <div class=\"mr-ring-in\">\n <span class=\"mr-ring-pct\" id=\"neo03-pct\">0%<\/span>\n <span class=\"mr-ring-sub\">net<\/span>\n <\/div>\n <\/div>\n <div class=\"mr-score-title\">Your Debrief<\/div>\n <div class=\"mr-score-net\" id=\"neo03-net\"><\/div>\n <div class=\"mr-verdict\" id=\"neo03-verdict\"><\/div>\n <div class=\"mr-bands\">\n <span class=\"mr-band mr-band-c\" id=\"neo03-ct-c\"><\/span>\n <span class=\"mr-band mr-band-w\" id=\"neo03-ct-w\"><\/span>\n <span class=\"mr-band mr-band-s\" id=\"neo03-ct-s\"><\/span>\n <\/div>\n <button class=\"mr-retry\" id=\"neo03-retry\">↻ New Round<\/button>\n <\/div>\n <\/div>\n\n <\/div>\n<\/div>\n\n\n<script>\n(function () {\n 'use strict';\n\n var NS = 'neo03';\n var TOTAL = 5;\n var MAX = 20;\n var LTRS = ['A','B','C','D'];\n\n var QS = [\n\n {\n id: 1,\n tag: 'Early-Onset Neonatal Sepsis — Antibiotic Choice',\n stem: 'A <strong>term neonate (38 weeks)<\/strong> born by normal vaginal delivery develops <strong>temperature instability, poor feeding, and respiratory distress at 18 hours of life<\/strong>. The mother had prolonged rupture of membranes for 24 hours and untreated <em>Group B Streptococcus (GBS)<\/em> colonisation detected at 36 weeks. WBC is 3,400\/mm³ (neutropenia), CRP is 32 mg\/L, blood culture is pending. What is the correct immediate antibiotic regimen?',\n correct: 'Intravenous benzylpenicillin plus gentamicin — narrow-spectrum cover for GBS with synergistic gram-negative activity',\n opts: [\n 'Intravenous benzylpenicillin plus gentamicin — narrow-spectrum cover for GBS with synergistic gram-negative activity',\n 'Oral amoxicillin alone — early-onset GBS sepsis in term neonates responds to oral beta-lactams',\n 'Intravenous vancomycin plus cefotaxime — required because GBS has intrinsic penicillin resistance',\n 'Withhold antibiotics until blood culture is positive — neutropenia in the first 24 hours is physiological'\n ],\n exp: '<strong>Early-onset neonatal sepsis (EOS)<\/strong> presents within <strong>72 hours<\/strong> of birth; the commonest organisms are <em>Group B Streptococcus<\/em> and gram-negative enteric bacilli (<em>E. coli<\/em>, <em>Klebsiella<\/em>). Risk factors here include maternal GBS colonisation, PROM >18 hours, and lack of intrapartum antibiotic prophylaxis. The empirical regimen of choice is <strong>IV benzylpenicillin<\/strong> (narrow-spectrum, highly effective against GBS) <strong>plus IV gentamicin<\/strong> (synergistic bactericidal cover against gram-negatives). GBS is <em>not<\/em> penicillin-resistant; vancomycin is not indicated. Blood culture must be obtained first, but <strong>treatment must not be delayed<\/strong> pending the result.',\n imgId: 'neo03-img1'\n },\n\n {\n id: 2,\n tag: 'Late-Onset Neonatal Sepsis — Organism & Source',\n stem: 'A <strong>26-week preterm male<\/strong> has been in the NICU for 18 days on total parenteral nutrition via a percutaneous central venous catheter (PICC line). He develops <strong>temperature instability, feed intolerance, apnoea, and a raised CRP<\/strong>. Blood culture grows a <strong>coagulase-negative Staphylococcus (CoNS)<\/strong>. The PICC line is still in situ. What is the most appropriate management?',\n correct: 'Start IV vancomycin and remove the PICC line — CoNS line-associated sepsis requires source control alongside antibiotics',\n opts: [\n 'Start IV vancomycin and remove the PICC line — CoNS line-associated sepsis requires source control alongside antibiotics',\n 'Start IV benzylpenicillin — CoNS is reliably penicillin-sensitive in neonates',\n 'Repeat the blood culture and withhold antibiotics — a single CoNS isolate always represents contamination',\n 'Start IV fluconazole — CoNS is a fungal pathogen requiring antifungal treatment'\n ],\n exp: '<strong>Late-onset sepsis (LOS)<\/strong> presents after 72 hours and is predominantly <strong>nosocomial<\/strong>. <strong>Coagulase-negative Staphylococci (CoNS)<\/strong> — especially <em>S. epidermidis<\/em> — are the single commonest cause of LOS in NICU, almost always associated with indwelling central venous catheters. CoNS forms biofilm on catheter surfaces and is typically <strong>methicillin-resistant<\/strong>, requiring <strong>vancomycin<\/strong>. A single blood culture isolate in a symptomatic neonate with a central line is <em>not<\/em> dismissed as contamination. <strong>Source control<\/strong> — removal of the PICC line — is essential alongside antibiotics; failure to remove the line leads to treatment failure and relapse.',\n imgId: null\n },\n\n {\n id: 3,\n tag: 'Neonatal Sepsis — Lumbar Puncture Decision',\n stem: 'A <strong>term neonate<\/strong> presents at 36 hours of life with <strong>seizures, bulging fontanelle, and high-pitched cry<\/strong>. Temperature is 38.8°C. WBC is 22,000\/mm³ with a left shift; CRP is 68 mg\/L. Blood culture has been sent. The team debates whether to perform a lumbar puncture before starting antibiotics. Which statement is MOST CORRECT?',\n correct: 'LP should be performed before antibiotics if the neonate is stable enough — meningitis cannot be excluded without CSF analysis and alters both treatment duration and choice',\n opts: [\n 'LP should be performed before antibiotics if the neonate is stable enough — meningitis cannot be excluded without CSF analysis and alters both treatment duration and choice',\n 'LP is contraindicated in neonates under 48 hours of age regardless of clinical signs',\n 'LP can safely be deferred for 72 hours as the CSF will remain interpretable after three days of IV antibiotics',\n 'A bulging fontanelle is a contraindication to LP due to risk of tentorial herniation in neonates'\n ],\n exp: '<strong>Neonatal meningitis<\/strong> occurs in up to 20–30% of bacteraemic neonates; blood culture alone cannot exclude it. CSF analysis is therefore <strong>mandatory in all neonates with confirmed or probable sepsis<\/strong> unless the baby is too haemodynamically unstable for the procedure. LP should ideally be performed <em>before<\/em> antibiotics because sterilisation of CSF can occur within hours, eliminating the ability to identify the organism and its sensitivity. Meningitis changes treatment: duration extends to 14–21 days (vs 7–10 days for sepsis alone) and some organisms (e.g. gram-negatives) require a third-generation cephalosporin added to the regimen. A bulging fontanelle reflects raised ICP but is <em>not<\/em> an absolute contraindication in a neonate — unlike in older children, tentorial herniation from LP is exceptionally rare.',\n imgId: null\n },\n\n {\n id: 4,\n tag: 'Neonatal Sepsis — Listeria monocytogenes',\n stem: 'A <strong>term neonate<\/strong> is born to a mother who consumed unpasteurised cheese at 37 weeks of pregnancy. The mother had a febrile illness with myalgia 2 weeks before delivery. The neonate is born with <strong>meconium-stained liquor at term, skin pustules, and hepatosplenomegaly<\/strong>. Blood culture grows a <strong>gram-positive bacillus<\/strong>. Which organism is most likely, and what is the critical antibiotic consideration?',\n correct: 'Listeria monocytogenes — it is intrinsically resistant to all cephalosporins; ampicillin plus gentamicin is required',\n opts: [\n 'Listeria monocytogenes — it is intrinsically resistant to all cephalosporins; ampicillin plus gentamicin is required',\n 'Group B Streptococcus — a gram-positive coccus sensitive to benzylpenicillin monotherapy',\n 'Staphylococcus aureus — treat with flucloxacillin; cephalosporins are first-line',\n 'Enterococcus faecalis — sensitive to vancomycin; cephalosporins provide adequate cover'\n ],\n exp: '<strong>Listeria monocytogenes<\/strong> is a gram-positive <em>bacillus<\/em> (not coccus) transmitted via contaminated food (soft cheeses, deli meats, smoked fish). Maternal infection causes a flu-like illness; fetal infection can cause preterm labour, meconium staining at term (unusual — an important clue), or early-onset neonatal sepsis with granulomatosis infantiseptica (skin pustules, hepatosplenomegaly). The critical pharmacology: <strong>Listeria is intrinsically resistant to ALL cephalosporins<\/strong>. Standard empirical regimens using cefotaxime or ceftriaxone will fail. Treatment is <strong>ampicillin (or amoxicillin) plus gentamicin<\/strong>. This is why benzylpenicillin + gentamicin (rather than a cephalosporin) is preferred for EOS — it covers Listeria; cephalosporins do not.',\n imgId: null\n },\n\n {\n id: 5,\n tag: 'Neonatal Candidiasis — Invasive Fungal Sepsis',\n stem: 'A <strong>24-week preterm female<\/strong>, now day 21 of life, has been on broad-spectrum antibiotics for 14 days for culture-negative suspected sepsis. She has a central line, is on TPN, and has received prolonged corticosteroids for BPD. She develops <strong>clinical deterioration with thrombocytopenia, hyperglycaemia, and a raised CRP<\/strong>. Blood culture grows <strong>Candida albicans<\/strong>. What is the correct management?',\n correct: 'Start IV amphotericin B or fluconazole, remove the central line, and perform ophthalmology review and echocardiography to exclude end-organ involvement',\n opts: [\n 'Start IV amphotericin B or fluconazole, remove the central line, and perform ophthalmology review and echocardiography to exclude end-organ involvement',\n 'Start oral nystatin alone — systemic candidiasis in neonates responds to topical antifungals',\n 'Continue current antibiotics and add metronidazole — Candida on blood culture represents gut colonisation, not true invasive infection',\n 'Fluconazole is contraindicated under 28 weeks corrected age; amphotericin B is the only option regardless of species sensitivity'\n ],\n exp: '<strong>Invasive candidiasis<\/strong> in VLBW\/ELBW neonates carries mortality up to 30%. Risk factors are classical here: extreme prematurity, prolonged broad-spectrum antibiotics, central line, TPN, and corticosteroids. <strong>Candida on blood culture is never dismissed<\/strong> as contamination in this setting. Management: (1) <strong>IV antifungal<\/strong> — fluconazole is first-line for susceptible <em>C. albicans<\/em>; liposomal amphotericin B for fluconazole-resistant species or renal impairment; (2) <strong>Remove the central line<\/strong> — source control is essential; (3) <strong>Ophthalmic review<\/strong> for Candida endophthalmitis; (4) <strong>Echocardiography<\/strong> to exclude endocarditis or intracardiac thrombus. Prophylactic oral fluconazole in ELBW neonates in high-incidence units is evidence-based and reduces invasive candidiasis.',\n imgId: null\n }\n\n ];\n\n\n var answers = {};\n var answered = 0;\n var shuffled = {};\n var done = false;\n\n function byId(id) { return document.getElementById(id); }\n function gid(suffix) { return byId(NS + '-' + suffix); }\n\n function shuffleArr(arr) {\n var a = arr.slice(), i, j, tmp;\n for (i = a.length - 1; i > 0; i--) {\n j = Math.floor(Math.random() * (i + 1));\n tmp = a[i]; a[i] = a[j]; a[j] = tmp;\n }\n return a;\n }\n\n function countVal(val) {\n var k, n = 0;\n for (k in answers) {\n if (answers.hasOwnProperty(k) && answers[k] === val) n++;\n }\n return n;\n }\n\n function buildPips() {\n var cont = gid('pips'), i, q, wLine, wPip, line, pip;\n cont.innerHTML = '';\n for (i = 0; i < QS.length; i++) {\n q = QS[i];\n if (i > 0) {\n wLine = document.createElement('div');\n wLine.className = 'mr-pip-wrap';\n line = document.createElement('div');\n line.className = 'mr-pip-line';\n line.id = NS + '-pl' + q.id;\n wLine.appendChild(line);\n cont.appendChild(wLine);\n }\n wPip = document.createElement('div');\n wPip.className = 'mr-pip-wrap';\n pip = document.createElement('div');\n pip.className = 'mr-pip';\n pip.id = NS + '-pip' + q.id;\n pip.textContent = String(q.id);\n wPip.appendChild(pip);\n cont.appendChild(wPip);\n }\n }\n\n function build() {\n var cont, i, q, opts, card, top, numDiv, meta, tag, stem,\n rule, optsDiv, expDiv, lbl, txt, imgDiv, imgSrc, j,\n optEl, ltrSpan, txtSpan;\n\n cont = gid('cases');\n cont.innerHTML = '';\n answers = {}; answered = 0; shuffled = {}; done = false;\n gid('score').style.display = 'none';\n buildPips();\n\n for (i = 0; i < QS.length; i++) {\n q = QS[i];\n opts = shuffleArr(q.opts);\n shuffled[q.id] = opts;\n\n card = document.createElement('div');\n card.className = 'mr-case';\n\n top = document.createElement('div');\n top.className = 'mr-case-top';\n\n numDiv = document.createElement('div');\n numDiv.className = 'mr-num';\n numDiv.textContent = q.id < 10 ? 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