A 3-day-old girl is brought to the emergency department due to irritability. The patient was discharged yesterday evening after an uncomplicated labor and vaginal delivery. Since last night, she has been crying during her wake periods and sleeping up to 7 hours at a time. She refused to feed this morning. Temperature is 37 C (98.6 F) and pulse is 180/min. Weight today is down 5% from birth. The patient is crying and unable to be consoled by the mother. The anterior fontanelle is soft. Cardiac examination reveals regular tachycardia and no murmurs. Lungs are clear to auscultation, and abdominal examination is normal. The skin is clear. Glucose is 70 mg/dL. Leukocyte count is 3,000/mm³. Which of the following is the most appropriate treatment of this patient's clinical presentation?

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11ec25c8_d5e9_5bd1_bc81_f54cd0844b20_MD0003_00 This neonate (age ≤28 days) is irritable with poor feeding and leukopenia, findings concerning for neonatal sepsis. The most common causes of early-onset (age <7 days) neonatal sepsis are group B Streptococcus (GBS) and Escherichia coli. Listeria monocytogenes also causes early-onset sepsis but typically occurs in outbreaks. Clinical manifestations of sepsis in neonates are often subtle and nonspecific, and a high index of clinical suspicion is required due to increased mortality with delayed diagnosis and treatment. Neonates with sepsis are often brought in for evaluation due to poor feeding, inconsolability, or lethargy. Temperature instability causing either fever or hypothermia (<36 C [96.8 F]), is common although patients may be normothermic, as seen in this neonate. An abnormal leukocyte count (increased or decreased) or elevated immature neutrophil count (bands) is also concerning for sepsis. Hemodynamically stable neonates with suspected sepsis warrant a full evaluation with a complete blood count, cerebrospinal fluid (CSF) analysis, urinalysis, and cultures of all 3 fluids (blood, urine, CSF). Patients should then receive empiric antibiotics with ampicillin, which targets GBS and L monocytogenes, along with gentamicin, which covers E coli and also acts synergistically with ampicillin against GBS and L monocytogenes. Acyclovir is often included in the empiric treatment regimen to cover herpes simplex virus. (Choice B) Ceftriaxone and vancomycin are used as empiric therapy for suspected sepsis in children age >1 month. Ceftriaxone, which does not cover L monocytogenes, is typically avoided in neonates due to its associated risk of hyperbilirubinemia. In addition, vancomycin is usually considered only in neonates with risk factors (eg, prolonged hospitalization) for methicillin-resistant Staphylococcus aureus. (Choice C) Neonatal hypoglycemia (<40 mg/dL) can cause irritability, lethargy, and poor feeding. This patient's glucose level is normal, making dextrose infusion unnecessary. (Choice D) Morphine may be indicated in neonatal abstinence syndrome, which occurs in neonates born to mothers who use opiates. Symptoms include irritability and poor feeding, not leukopenia. (Choice E) Propranolol can treat neonatal Graves disease, which can cause tachycardia and irritability due to thyroid stimulation from transplacental transfer of maternal antithyroid antibodies. However, in this case, there is no maternal history of Graves disease, and associated symptoms such as excessive eating and hepatosplenomegaly are not present. Educational objective: Neonatal sepsis typically causes nonspecific symptoms, including irritability, poor feeding, and lethargy. An abnormal leukocyte count is common. Empiric therapy is intravenous ampicillin and gentamicin to treat the most common pathogens, including group B Streptococcus, Escherichia coli, and Listeria monocytogenes. References: Empiric antibiotics for serious bacterial infection in young infants: opportunities for stewardship. (http://www.ncbi.nlm.nih.gov/pubmed/25822235)

A 3-Day-Old Girl Is Brought to the Emergency Department Due