Transcript
Dr. Rahat bin Habib. MDDr. Rahat bin Habib. MDICMH, Matuail, Dhaka.ICMH, Matuail, Dhaka.
SEPSIS IN NEWBORNSEPSIS IN NEWBORN
All newborns enter an unsterile All newborns enter an unsterile environment,but infection develops in environment,but infection develops in
only a few.only a few.
ABSTRACTABSTRACT
****Infections are the single largest cause of neonatal Infections are the single largest cause of neonatal death globally.death globally.
**Clinical features of sepsis are non-specific in **Clinical features of sepsis are non-specific in neonates and a high index of suspicion is required neonates and a high index of suspicion is required for the timely diagnosis of sepsis.for the timely diagnosis of sepsis.
**It is responsible for about 30-50%of the total **It is responsible for about 30-50%of the total neonatal deaths in developing countries. neonatal deaths in developing countries.
**Neonatal death in our country is 37/1000 live **Neonatal death in our country is 37/1000 live birth. birth.
**sepsis related mortality is largely preventable **sepsis related mortality is largely preventable with rational antimicrobial therapy and aggressive with rational antimicrobial therapy and aggressive
supportive care.supportive care.
DEFINITIONDEFINITION
Neonatal sepsis is a clinical syndrome of Neonatal sepsis is a clinical syndrome of bacteremia characterized by systemic signs and bacteremia characterized by systemic signs and symptoms of infection in the first month of life.symptoms of infection in the first month of life.
Factors influencing neonatal septicemiaFactors influencing neonatal septicemia
1. Transmission of infection1. Transmission of infection ….transplacental ….transplacental
….vertical ….vertical ….from environment ….from environment
2. Immunologic deficiency2. Immunologic deficiency ….immunoglobulin ….immunoglobulin
….complement ….complement ….leukocyte ….leukocyte ….cytokines ….cytokines ….antibody ….antibody
Factors influencing neonatal Factors influencing neonatal septicemia…..contsepticemia…..cont
3. Gestational age & birth weight3. Gestational age & birth weight
4. Physical defence4. Physical defence ……poor skin condition. ……poor skin condition. ……raw umbilical stump. ……raw umbilical stump.
5. Advanced neonatal care.5. Advanced neonatal care.
Classification of neonatal sepsisClassification of neonatal sepsis
Neonatal sepsis can be classified into two major Neonatal sepsis can be classified into two major group : group :
1. Early onset sepsis: It presents 1. Early onset sepsis: It presents
within 7 days of life , usualy within 7 days of life , usualy
within 72 hours. within 72 hours.
2. late onset sepsis: It usually 2. late onset sepsis: It usually
presents after 7 days of lifepresents after 7 days of life
Charecteristics differenceCharecteristics difference
charecteristicscharecteristics EONSEONS LONSLONS
Age of onsetAge of onset Birth to 7 days, Birth to 7 days, usually within 72 usually within 72 hourshours
7 to 30 days7 to 30 days
Maternal obstetric Maternal obstetric complicationcomplication
commoncommon uncommonuncommon
prematurityprematurity frequentfrequent variesvaries
Organism sourceOrganism source Maternal genital Maternal genital tracttract
Maternal genital Maternal genital tract, environmenttract, environment
menifestationmenifestation multisystemmultisystem Multisystem, focalMultisystem, focal
Risk FactorsRisk Factors
Low birth weight (<2500gm) or Prematurity.Low birth weight (<2500gm) or Prematurity. Febrile illness in the mother within 2 weeks prior Febrile illness in the mother within 2 weeks prior
to delivery.to delivery. Foul smelling and/or meconium stained liquor.Foul smelling and/or meconium stained liquor. Rupture membrane for more than 24 hours.Rupture membrane for more than 24 hours. Single unclean or >3 sterile vaginal examination.Single unclean or >3 sterile vaginal examination. Prolonged labor.Prolonged labor. Severe perinatal asphyxia.Severe perinatal asphyxia.
EtiologyEtiology
Most common bacterial causes ofMost common bacterial causes of neonatal sepsis are:neonatal sepsis are: Klebsiella Klebsiella ActinatobacterActinatobacter E.ColiE.Coli PseudomonasPseudomonas Strep.pyogenStrep.pyogen Strep.PneumoniaeStrep.Pneumoniae Staphylococcus aureusStaphylococcus aureus
Organism responsible for sepsisOrganism responsible for sepsis
study in Dhaka Shishu Hospitalstudy in Dhaka Shishu Hospital
…….E. coli………………..30% …….E. coli………………..30% …….Klebsiela…………….23% …….Klebsiela…………….23% …….Staph. Aureus…….17% …….Staph. Aureus…….17% …….Pseusdomonus…..10% …….Pseusdomonus…..10% …….Streptococcus sp…10% …….Streptococcus sp…10% …….Acinatobacter……..10% …….Acinatobacter……..10%
Organism responsible for sepsis Organism responsible for sepsis
According to Nelson textbook….According to Nelson textbook….
……coagulase neg. staph. Aureus..29% ……coagulase neg. staph. Aureus..29% ………staph aureus……………………..08% ………staph aureus……………………..08%
………B hemolytic streptococci……..21% ………B hemolytic streptococci……..21% ……..E. coli……………………………….11% ……..E. coli……………………………….11% ……..Klebsiella……………………………11% ……..Klebsiella……………………………11% ………Pseudomonus……………………03% ………Pseudomonus……………………03% ………Fungus……………………………..08% ………Fungus……………………………..08%
Organism responsible for sepsis Organism responsible for sepsis
study in indiastudy in india ………Klebsiela ….………32.5% ………Klebsiela ….………32.5% ………staph. Aureus……13.6% ………staph. Aureus……13.6% ………pseudomonus……13% ………pseudomonus……13%
study in nepalstudy in nepal ……staph aureus……………………….38.8% ……staph aureus……………………….38.8%
……coagulase neg. staph. Aureus…21% ……coagulase neg. staph. Aureus…21% …….Klebsiela pn…………………………11.6% …….Klebsiela pn…………………………11.6% …….enterobac…………………………….9.7% …….enterobac…………………………….9.7%
ICMH DATA -2009ICMH DATA -2009
Total blood culture sample - 924Total blood culture sample - 924Growth of organism – 101Growth of organism – 101Percent of growth – 11%Percent of growth – 11%
ICMH DATA 2010ICMH DATA 2010 January – AprilJanuary – April Total Sample – 306Total Sample – 306 Growth of organisms - 86Growth of organisms - 86 % of growth – 28%% of growth – 28% Among the organismsAmong the organisms
…… ……..Staph. Aureus…….51%Staph. Aureus…….51% ……… ……….Acenatobacter……..25%.Acenatobacter……..25%
… ….E. coli………………..14%.E. coli………………..14% … ….Klebsiela……………. 03% … ….Klebsiela……………. 03% …….Pseudomonas…..03% …….Pseudomonas…..03%
Clinical features Clinical features
General:General: fever or hypothermia,fever or hypothermia, poor feeding, poor feeding, Lethargy,Lethargy, poor activity,poor activity,
Skin changeSkin change:: purpura, petechiae, Multiple purpura, petechiae, Multiple
pustules, Abscess, Sclerema, pustules, Abscess, Sclerema, Umbilical redness and discharge Umbilical redness and discharge
CNSCNS:: Irritability, seizure, hyporeflexia Irritability, seizure, hyporeflexia
Abnormal Moro reflex Abnormal Moro reflex Bulge fontanels , Bulge fontanels ,
Vacant stare, Vacant stare, High-pitched cry High-pitched cry
RespiratorRespiratory :y :
cyanosis, cyanosis,
apnea, tachypnea,apnea, tachypnea,
chest indrawning,chest indrawning,
nasal flaring,nasal flaring,
intercostal recession,intercostal recession,
GIT GIT ::
feed intolerance, feed intolerance, vomiting, diarrheavomiting, diarrhea
abdominal distension, abdominal distension, paralytic ileus,paralytic ileus,
necrotizing enterocolitis.necrotizing enterocolitis.
CVSCVS:: Poor perfusion, tachycardia, Poor perfusion, tachycardia,
bradycardia, hypotension, shock bradycardia, hypotension, shock
HepaticHepatic : : hepatomegaly, direct hyperbilirubinemia hepatomegaly, direct hyperbilirubinemia
Renal Renal :: acute renal failure acute renal failure
INVESTIGATIONINVESTIGATION
Treatment should be initiated in a neonate without Treatment should be initiated in a neonate without any delay, Only minimal and rapid investigations any delay, Only minimal and rapid investigations should be undertaken.should be undertaken.
1. 1. BLOOD CULTUREBLOOD CULTURE : :
It is the gold standard for diagnosis of It is the gold standard for diagnosis of septicemia and should be performed in all cases septicemia and should be performed in all cases of suspected sepsis prior to starting antibiotics. of suspected sepsis prior to starting antibiotics.
blood c/s (-)….80% caseblood c/s (-)….80% case blood c/s (+)…..20% caseblood c/s (+)…..20% case single org….97%single org….97% ( ref : 2 yrs study in nepal 2006 & ‘07)( ref : 2 yrs study in nepal 2006 & ‘07)
INVESTIGATION……..contINVESTIGATION……..cont
2. 2. SEPTIC SCREENSEPTIC SCREEN : :
Total leukocyte count <5000/mm Total leukocyte count <5000/mm Absolute neutrophil count Absolute neutrophil count
Immature/total neutrophil count >0.2 Immature/total neutrophil count >0.2 Micro ESR- >15 mm in 1 Micro ESR- >15 mm in 1stst hour hour C-reactive protein- >1o mg/dl C-reactive protein- >1o mg/dl
Comes atComes at Peak level atPeak level at
CRPCRP 7 hr7 hr 24 hr24 hr
ANC, I/T ratioANC, I/T ratio 22 hr22 hr 48 hr48 hr
Micro ESRMicro ESR 26 hr26 hr 48-72 hr48-72 hr
Investigation…….cont Investigation…….cont
3. 3. Lumber puncture:Lumber puncture:
In EOS:In EOS:
Positive blood culturePositive blood culture
oror
Clinical picture is consistent with septicemia. Clinical picture is consistent with septicemia.
In LOS:In LOS:
LP should be done in all infants prior to LP should be done in all infants prior to
starting antibiotics.starting antibiotics.
Investigation......contInvestigation......cont
4.4. Chest X-ray:Chest X-ray:
Should be considered in the presence ofShould be considered in the presence of
respiratory distress or apnea.respiratory distress or apnea.
5. 5. Urine for R/M/E & C/S.Urine for R/M/E & C/S.
from suprapubic puncture or catheterization.from suprapubic puncture or catheterization.
6. Hb%, platelet count, Blood sugar, Serum 6. Hb%, platelet count, Blood sugar, Serum electrolytes, X-ray abdomen-(if necessary) electrolytes, X-ray abdomen-(if necessary)
ManagementManagement
Supportive:Supportive:
1. Maintain body temperature.1. Maintain body temperature. 2. Provide oxygen if indicated.2. Provide oxygen if indicated. 3. Monitoring and correction of hypoglycemia.3. Monitoring and correction of hypoglycemia. 4. Infusion Normal saline if perfusion is poor. 4. Infusion Normal saline if perfusion is poor. 5. Blood transfusion if indicated.5. Blood transfusion if indicated. 6. Ensure feeding if possible breast feeding, 6. Ensure feeding if possible breast feeding, or give N-G tube feed with EBM, if the or give N-G tube feed with EBM, if the baby is very sick, can not tolerate oral feed baby is very sick, can not tolerate oral feed or suspected NEC give I/V fluidor suspected NEC give I/V fluid
Antimicrobial therapyAntimicrobial therapy
Indication in EOS……any 1 0f the followingIndication in EOS……any 1 0f the following
Presence 3 or more risk factors.Presence 3 or more risk factors. Presence of foul smelling liquor.Presence of foul smelling liquor. Two risk factors and a positive Two risk factors and a positive septic screen.septic screen. Strong clinical suspicion of sepsis.Strong clinical suspicion of sepsis.
Indication in LOS…….Indication in LOS……. Positive septic screenPositive septic screen oror Strong clinical suspicion of sepsisStrong clinical suspicion of sepsis
Empirical choice of antibioticsEmpirical choice of antibiotics
First lineFirst line
ampicillin + gentamycinampicillin + gentamycin Second lineSecond line
cefotaxime/ceftazidimecefotaxime/ceftazidime
+ +
amikacinamikacin Third lineThird line
ciprofloxacin/meropenum/imipenumciprofloxacin/meropenum/imipenum
If intestinal pathology suspected.……add metronidazoleIf intestinal pathology suspected.……add metronidazole
If nosocomial infection suspected……add cloxacillinIf nosocomial infection suspected……add cloxacillin
Doses of common antibiotics Doses of common antibiotics
Ampicillin: 50-100 mg/kg/dAmpicillin: 50-100 mg/kg/d
100-200 mg/kg/d in meningitis100-200 mg/kg/d in meningitis
Gentamycin: 5-7.5 mg/kg/dGentamycin: 5-7.5 mg/kg/d
Amikacin: 15-30 mg/kg/dAmikacin: 15-30 mg/kg/d
Cloxacillin: 50-100 mg/kg/dCloxacillin: 50-100 mg/kg/d
100-200 mg/kg/d in meningitis100-200 mg/kg/d in meningitis
Cefotoxime: 150 mg/kg/dCefotoxime: 150 mg/kg/d
200 mg/kg/d in meningitis 200 mg/kg/d in meningitis
Ceftazidime : 100-150 mg/kg/dCeftazidime : 100-150 mg/kg/d
Duration of treatmentDuration of treatment
Meningitis : Meningitis : 21 days21 days
Blood culture positive but no meningitis : Blood culture positive but no meningitis : 14 days14 days
Culture negative, sepsis screen positive and clinical Culture negative, sepsis screen positive and clinical course consistent with sepsis: course consistent with sepsis: 7 to 10 days7 to 10 days
All are negative but clinical course compatible with All are negative but clinical course compatible with sepsis: sepsis: 5 to 7 days5 to 7 days
All are negative & clinical course not compatible All are negative & clinical course not compatible with sepsis : with sepsis : stop antibiotics afterstop antibiotics after 3 days3 days
PreventionPrevention
maternal carematernal care
1. maintain maternal nutrition. 1. maintain maternal nutrition. 2. early diagnosis of maternal disease like 2. early diagnosis of maternal disease like DM, HTN & take appropriate measure. DM, HTN & take appropriate measure.
3. early diagnosis of maternal infection like 3. early diagnosis of maternal infection like UTI, chorioamnionitis & prompt treatment. UTI, chorioamnionitis & prompt treatment.
4. avoid unnecessary p/v exam. 4. avoid unnecessary p/v exam.
PreventionPrevention
Essential new born care:Essential new born care:
1. Clean delivery & clean cord care.1. Clean delivery & clean cord care.
2. Encouraging early & exclusive breast 2. Encouraging early & exclusive breast
feeding.feeding.
3. Hand washing before& after handling 3. Hand washing before& after handling
each baby.each baby.
4. Extra care for low birth weight baby . 4. Extra care for low birth weight baby .
PreventionPreventionNursery care:Nursery care:
1. Hand washing which includes 2 min scrub 1. Hand washing which includes 2 min scrub
before entering the nursery & 15 sec in between before entering the nursery & 15 sec in between
patientspatients
2. Strict routine for washing, disinfection & 2. Strict routine for washing, disinfection &
cleaning of cotscleaning of cots
3. Avoidance of overcrowding & of visit of an 3. Avoidance of overcrowding & of visit of an
infected staff or a relative. infected staff or a relative.
4. Isolation of infected infant in a separate cots.4. Isolation of infected infant in a separate cots.
5. minimal handling.5. minimal handling.
6. Skin care to maintain integrity of skin & cord care.6. Skin care to maintain integrity of skin & cord care.7. prompt antibiotic therapy for suspected/diagnosed 7. prompt antibiotic therapy for suspected/diagnosed
case. case.8. change bed cloth after bowel/bladder movement.8. change bed cloth after bowel/bladder movement.
9. aseptic technique for all sorts of procedure.9. aseptic technique for all sorts of procedure.10. routine change of NG tube & IV canulla10. routine change of NG tube & IV canulla
Statistical data of ICMHStatistical data of ICMHYearYear Total Total
neonatal neonatal admisionadmision
Neonatal Neonatal septicemia septicemia adm.adm.
%% Total Total neonatal neonatal deathdeath
Septicemic Septicemic pt deathpt death
%%
20072007 28422842 558558 19.63%19.63% 471471 139139 25%25%
20082008
20092009
20102010
23392339
22802280
560560
467467
441441
193193
20%20%
19.3%19.3%
34.46%34.46%
350350
319319
131131
157157
28%28%
29%29%
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