• The presence of bacteria in tracheal secretions stained by the Gram method was evaluated as a method of predicting neonatal bacteremia. The presence of bacteria had a 74% sensitivity and a 47% predictive accuracy in identifying neonates with bacteremia before 12 hours of age. The specificity in predicting newborns without bacteremia was 98%. In the same neonates, an immature neutrophil-total neutrophil ratio of 0.2 or more had a 77% sensitivity in predicting neonates with bacteremia. Neonates with bacteria in their blood and tracheal aspirates, who died shortly after birth, had pneumonia on postmortem examination. In newborns who have respiratory distress and a risk of infection at birth, Gram's stains of tracheal secretions are a practical and useful method of predicting congenital bacteremia.