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Discussion

Neonatal sepsis is a life-threatening diagnosis, with a reported incidence of 1–4 per 1000 live births in the United States. 1 Common culprit bacteria in the neonatal (< 30 d) age group include GBS, Escherichia coli and other gram-negative bacilli, thought to be acquired through vertical transmission from the maternal genitourinary tract. 2 In Canada, missed meningitis is a common complaint to the Canadian Medical Protection Association, with most cases concerning children aged 0–4 years. 3 Citrobacter koseri is a gram-negative bacterium that is universally resistant to penicillin; it is a rare cause of neonatal meningitis. Casefatality rates in neonates are about 30%, with 70% of cases developing brain abscess and 50% of survivors left with longterm neurologic sequelae. 4

In neonates presenting with parental concerns of fussiness, clinicians should ask about increased lethargy, change in behaviour, decrease in wet diaper frequency and volume, reduced feeding and antenatal risk factors for serious bacterial infection. The patient should be examined for clinical signs of serious bacterial infection, such as tachypnoea, tachycardia, fever, signs of dehydration (eg, delayed capillary refill, lethargy), signs of an intracranial process (eg, atonia, irritability, inconsolability, bulging fontanelles), increased work in breathing (eg, tachypnea, recessions, head bobbing) and jaundice. Clinical features of serious bacterial infection may be subtle, and several clinical decision tools have been derived to aid clinicians