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NEONATAL SEPSIS
Joanne Ang
Pediatrics Rotation – Nursery
INTRODUCTION Infection – important cause of neonatal
and infant morbidity and mortality
2% of fetuses are infected in utero 10% of infants have infections in the 1st
month of life
INTRODUCTION Neonatal Infections are unique
1.)infectious agents can be transmitted from the mother- transplacentally -ascending bacterial infections – maternal chorioamnionitis, PROM, resuscitation at birth
2.)newborn are less capable of responding to infections
3.)clinical manifestation vary and include subclinical , mild to severe manifestations
INTRODUCTION Neonatal Infections are unique
4.)maternal infection is often undiagnosed during pregnancy
5.)Wide variety of etiologic agents
6.)Immature and Very Low Birth weight remain in hospital for a long time which puts them at continuous risk for acquired infections
- Maternal infection that is the source of transplacental infection is often undiagnosed during pregnancy because the mother was either asymptomatic or had nonspecific signs and symptoms.
- Bacteria, viruses, fungi, protozoans and mycoplasmas.
CHORIOAMNIONITIS Criteria
Fever (Temperature of > 37.8 C) plus two or more of the following Maternal tachycardia (>100 bpm) Fetal tachycardia (>160 bpm) Uterine tenderness Malodorous or cloudy amniotic fluid Maternal WBC count >15,000 cells/cubic mm
The neonate is unable to respond effectively to infectious hazards because of deficits in the physiological response to infectious agents!
The neonatal neutrophil or polymorphonuclear (PMN) cell, which is vital for effective killing of bacteria, is defective in chemotaxis and killing capacity.
Decreased adherence to the endothelial lining of blood vessels reduces their ability to marginate and leave the intravascular area to migrate into the tissues.
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Once in the tissues, they may fail to deaggregate in response to chemotactic factors.
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Also, neonatal PMNs are less deformable; therefore, they are less able to move through the extracellular matrix of tissues to reach the site of inflammation and infection.
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The limited ability of neonatal PMNs for phagocytosis and killing of bacteria is impaired when the infant is clinically ill.
Lastly, neutrophil reserves are depleted easily because of the diminished response of the bone marrow, especially in the premature infant.
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ETIOLOGY The following are transplacentally
transmitted:ToxoplasmosisSyphilisCytomegalovirusParvovirus B19Varicella
ETIOLOGY The following are transplacentally and
intrapartally transmitted:Herpes Simplex VirusHIVHepatitis B and C virusTuberculosis
CLINICAL MANIFESTATION OF TRANSPLACENTAL INFECTIONS
CLINICAL MANIFESTATION OF TRANSPLACENTAL INFECTIONS
CLINICAL MANIFESTATION OF TRANSPLACENTAL INFECTIONS
SIGNS AND SYMPTOMS OF INFECTION
MOST COMMON ETIOLOGIES OF SEPSIS IN THE NEWBORN E. Coli Group B Streptococcus Listeria monocytogenes
RISK FACTORS ASSOCIATED WITH NEONATAL SEPSIS
RISK FACTORS ASSOCIATED WITH NEONATAL SEPSIS
Neonatal Risk FactorsTerm male infants have 2x higher than
femalePre-term have a 3-10x higher incidence of
infection than termLow Birth weight
WHAT IS SEPSIS?
NEONATAL SEPSIS
NEONATAL SEPSIS – EARLY ONSET Predisposing factors:
*Maternal group B Streptococcus (GBS) colonization (especially if untreated during labor)
*Premature rupture of membranes (PROM), preterm rupture of membranes, prolonged rupture of membranes
*Prematurity*Maternal urinary tract infection (3rd trimester)*Maternal Chorioamnionitis (WBC>18)
PREDOMINANT PATHOGENS Early Onset Sepsis
E.coliGroup B streptococcusListeriaHemophilus influenzaEnterobacter aeruginosaKlebsiella pneumoniaPseudomas aeruginosaStaphylococcus aureus
NEONATAL SEPSIS – LATE ONSET occurs at 7-90 days of life Prematurity, prolonged hospitalization,
presence of foreign bodies like umbilical catheters, ET tube, parenteral alimentation, prior use of antibiotics
Predominant pathogens:coagulase negative Staphylococcus
epidermidis, Staphylococcus aureus, Candida, Enterococcus, E coli, Klebsiella, Pseudomonas aeroginosa, GBS, Serratia, Acinetobacter, Anaerobes
SIGNS AND SYMPTOMS OF SEPSIS Respiratory distress
TachypneaRetractionsGruntingNasal flaringApnea
Abnormal skin color perfusionPale color or gray colorDelayed capillary refill time jaundice
SIGNS AND SYMPTOMS OF SEPSIS Temperature instability
Hypothermia and rarely, hyperthermia Feeding intolerance
VomitingDiarrheaAbdominal distention
Abnormal HR and BPTachycardia, bradycardia, hypotension
Abnormal neurologic statusLethargy, hypotonia, seizures
DIAGNOSISThe diagnosis of systemic infection in the
newborn is difficult to establish on the basis of clinical findings alone.
Any infant who suddenly changes for the worse should be suspected for sepsis.
LABORATORY DIAGNOSISBlood cultureCSF cultureUrine cultureCBCAcute phase reactants: ESR and CRPChest X-ray
SEPSIS SCREEN Because none of the diagnostic tests for
sepsis is able to identify infants with proven sepsis with reasonable accuracy, investigators have used combinations of laboratory tests to enhance the identification of infected neonates.
Because of its high negative predictive accuracy, it can provide a greater reassurance that an infection is not present.
SEPSIS SCREEN A positive sepsis screen result was
defined as two or more abnormal test results.Sensitivity = 93%Positive predictive accuracy of 39%
< 2 abnormal results = 99% negative predictive accuracy
MANAGEMENT
RISK FACTORS ASSOCIATED WITH NEONATAL SEPSIS
RISK FACTORS ASSOCIATED WITH NEONATAL SEPSIS
Neonatal Risk FactorsTerm male infants have 2x higher than
femalePre-term have a 3-10x higher incidence of
infection than termLow Birth weight
MANAGEMENT
MANAGEMENT
TREATMENT Initial empiric therapy for early onset sepsis
Ampicillin plus aminoglycoside (usually gentamicin or cefotaxime)
Antibiotic therapy should be tailored according to its sensitivities L. monocytogenes -> Aminoglycoside + ampicillin Enterococci -> Amoxicillin + aminoglycoside or
vancomycin GBS -> Penicillin or ampicillin S. aureus -> Penicillase resistant penicillins or
cephalosporins; MRSA – vancomycin, clindamycin P. aeruginosa -> Ticarcillin, carbenicillin and an
aminoglycoside; Most are sensitive to Ceftazidime Gram negative enteric organisms ->Generally sensitive
to aminoglycoside
TREATMENT Initial empiric therapy for late onset
sepsisAmpicillin plus cefotaxime; vancomycin +
gentamicin; vancomycin+cefotaxime With minimal or no focal infection
usually 7-10 days With meningitis caused by group B
streptococcus or gram negative enteric bacilli at least 21 days
SUPPORTIVE MEASURES Maintenance of normal body
temperature Maintenance of adequate nutrition Proper hydration Monitoring of electrolytes and glucose Ventilatory support if needed
THANK YOU