Neonatal sepsis

NEONATAL SEPSIS

.

Neonatal Sepsis

Clinical syndrome of bacteraemia with

systemic signs and symptoms of infection in the first four weeks of life.

Burden of Neonatal Sepsis Worldwide: 1.5-2 million deaths per year In developing world: 30-50% of neonatal

deaths (4000-5000 deaths per day) Commonest cause of neonatal mortality

and morbidity 20% of all neonates develop infection 1% of all neonates die of infectionSepsis related deaths are

preventable

Incidence of neonatal sepsis

Indian Data NNPD - Neonatal sepsis-38/1000 live

births

Meningitis- 0.5/1000 live births

  CMC – Neonatal sepsis 9.8/1000 live

births

TERMINOLOGY At risk of sepsis: maternal risk factors for

infection present, baby is clinically well, sepsis screen is negative

Probable sepsis: baby has clinical features of sepsis, risk factors and screening tests ±, blood culture is negative

Sepsis: baby has clinical features of sepsis and blood culture is positive

Spectrum of illness Sepsis

Pneumonia

Meningitis

Osteomyelitis

Early Vs Late Onset Sepsis

EOS Onset

<48 hours Source

Maternal

LOS

>48 hours

Environmental

Aetiological agents

EOS LOS

E.coli KlebsiellaGBS EnterobacterEnterococcus Coagulase -

Negativestaphylococci

Risk factors for neonatal sepsisEOS Preterm premature

rupture of membranes Prolonged rupture of

membranes >24 hours Maternal fever Chorioamnionitis Foul-smelling liquor Urinary tract infection Multiple vaginal

examinations

LOS Preterm Low birth weight Formula feeding Invasive procedures Parenteral fluids Overcrowding Understaffing Lack of asepsis

Vulnerability Immature immune system Unavoidable exposure to pathogenic

organisms in birth canal Peripartum stress Invasive procedures Exposure to highly resistant

nosocomial organisms in NICU

Clinical Features

Not breathing well

Not feeding well

Not looking well

Respiratory Dusky spells Tachypnea Apnea Increased Apnoea,

Bradycardia episodes

Feeding Not hungry Distension Residuals Vomiting Heme-positive stools Watery or mucousy

stools

Appearance Lethargic Mottled Poor perfusion Temperature

instability Early-onset jaundice

Ominous Late Signs Apnea Seizures Hypotension/ Shock

Central Nervous SystemLethargy / irritabilityJitteriness / hyporeflexiaTremors / seizuresComaFull fontanelleAbnormal eye movementsHypotonia / increased tone

Respiratory SystemCyanosisGruntingIrregular respirationTachypnoea / apnoeaRetractions

Haematopoietic SystemJaundiceBleedingPurpura / ecchymosisSplenomegaly

SkinRashes / erythemaPurpuraPustules / paronychiaOmphalitisSclerema

Circulatory SystemPallor / cyanosis / mottlingCold, clammy skinTachycardia / arrhythmiaHypotensionOedema

Gastrointestinal tractPoor feedingVomiting (may be bile-stained)Diarrhoea /decreased stoolsAbdominal distensionOedema / erythema abdominal wallHepatomegaly

CLINICAL SIGNS OF NEONATAL SEPSIS

Diagnosis

Gold standard: positive blood culture

Goals of workup Recover organism Determine specific antibiotics Determine antibiotic doses Determine length of therapy

 Remember that 10 babies are worked up for each proven case

Screening TestsSepsis Screen Leukopenia (TLC <5000/cu mm) Neutropenia (ANC <1800/cu mm) Immature to total neutrophil ratio (I/T) >0.2 CRP +ve >10 mcg/ml after 24 hrs Micro-ESR >15 mm in 1st hour

*If two or more screening tests are positive, treat infant as neonatal sepsis

Other Tests CIE/ Latex agglutination for GBS Gastric aspirate/ ET aspirate Buffy coat

Classic Septic Workup Blood culture Lumbar Puncture Urine (suprapubic aspirate) Endotracheal Tube aspirate (if intubated) Surface cultures – ear/skin/eye secretions Stool culture Chest X-Ray Abdominal X-ray

Meningitis 20-30% of cases have meningitis Meningitis can often be clinically

missed LP must be done if there are clinical

signs of meningitis and in all cases of bacteraemia

RECENT ADVANCES IN DIAGNOSIS

Computer assisted automated blood culture system

Procalcitonin Cytokine levels estimation - IL1β,IL 6,

IL 8,TNF

Supportive care Thermoregulation Fluid and electrolyte balance Maintain normoglycemia Maintain tissue perfusion Avoid enteral feeds if baby is sick Provide adequate calories, TPN Support respiration Dopamine/ dobutamine Exchange transfusion

Choice of antibiotics

EARLY ONSET SEPSIS Penicillin/ampicillin

+ Aminoglycoside

(gentamicin/amikacin)

LATE ONSET SEPSIS Cefotaxime Amikacin Ciprofloxacin Vancomycin Carbapenems

How long to treat? Negative cultures AND course not consistent

with infection: 48-72 hours treatment

Sepsis/ NEC10-14 days treatment

Meningitis14 days (Gram-positive), 21 days (Gram-negative)

Osteomyelitisprolonged treatment

UTI7-10 days treatment, screen for renal anomalies

Immunologic Therapy

Intravenous Immunoglobulin (IVIG) Granulocyte - Colony Stimulating Factor

(G-CSF), Granulocyte Macrophage - Colony Stimulating Factor (GM-CSF)

Neutrophil transfusion Fresh Frozen Plasma Exchange transfusion

Targeting Inflammatory Mediators

1. Anti endotoxin

2. Anti cytokine therapy Anti TNF - antibody Interleukin-1 Receptor antibody (IL-1 RA) IL - 10 (Inhibits TNF, IL-1, IL-12)

3. PAF Antagonists

4. Nitric Oxide (NO) Synthase inhibitors

5. Guanylate Cyclase inhibitor

Methylene blue

Outcome Birth weight, gestational age Treatment delay EOS or LOS Associated complications Perinatal centre

Case Fatality Rate India, Pak, SE Asia : 27-69% Middle East: 13-28% Vellore: 14.4%

EOS : 16.7%LOS : 13.6%

Sepsis accounted for 19% of all deaths

Prevention Intrapartum Antibiotic Prophylaxis

GBS carriersMothers with PROM/PPROMMothers with other recognisable risk factors for infection

GBS vaccine

0.25% ChlorhexidineWashing birth canal during each vaginal examinationWiping the baby after delivery

General measures Handwashing Isolation? Bedside asepsis Disposal of waste products in separate bins Glucose, protein, and lipid solutions should not be re-

used Intravenous in-line bacterial and viral filters Avoid overcrowding Adequate staff Periodic surveillance Regular cleaning of the unit Exclusive use of breast milk Treat LOS as a medical emergency

CONGENITAL INTRAUTERINE

INFECTIONS

Defn: Infection acquired transplacetally while inutero.

AetiologyCommon organisms

Toxoplasma Others: HIV,EBV,

ParvoB19

Rubella Cytomegalovirus Herpes simplex Syphylis

Uncommon organisms Varicella zoster Listeria Myc tuberculosis

Perinatal infections Infections transmitted just before

delivery Clinical features are similar to any post

natal infection Examples : Group B streptococcus Listeria Enteroviruses

Common clinical features of TORCH infections

Growth retardation Hepatospleenomegaly Jaundice Hemolytic anaemia Petichae, echymosis Microcephaly Intra-cranial

calcifications

Pneumonitis Myocarditis Heart defects Chorioretinitis Cataract Glaucoma Hydrops

Clinical features suggesting a specific diagnosis

Rubella : eye – cataract, keratitis, retinitis skin – “blueberry muffins” heart – PDA, pulmoic stenosis Deafness CMV: microcephaly with periventricular

calcifications, petichae, thrombocytopenia Toxoplasma : hydrocephalus with diffuse

intrcerebral calcifications Syphilis : bone and mucocutaneous lesions

Diagnostic approach

Nonspecific tests CBC, platalet

counts CSF analysis Xray of long bones CT scan of brain Eye checkup Hearing assesment

Specific tests Viral culture: urine,

blood, stool, csf Skinsmears: tzank

sm. Specific serology

Congenital rubella syndrome

Transplacental passage of virus early in pregnancy affects organogenesis in fetus

Multisystem involvement Infection before 11th week – 90% chance Infection after 16th week – low risk Ask for low grade transient fever, posterior

auricular and suboccipital tender lymphadenopathy, arthralgia and rashes in 1st trimester

CRS contd…

Clinical features Diagnosis:1. baby’s serum +ve for rubella Igm2. viral culture of secretions3. isolation from amniotic fluid – prenatally Prognosis:1. Extensive involvement – grim prognosis2. Fewer stigmata – better Prevention:1. rubella/ MMR vaccine – 90% protective2. Abortion / immunoglobulin in exposed seronegative

mothers

Syphilis

Transplacental infection at any stage of pregnancy – sply 1*, 2* or early latent phase

100 % transmission rates Perinatal death in 40% Risk factors in mother/father Classic perinatal history : 1st trimester abortion 2nd trimester aboprtion 3rd trimester fetal loss, FSB Early neonatal death Affected infant

Syphilis – clinical featuresEarly signs(1st 2

years) Hepatospleenomegaly Lymphadenopathy Hemolytic anaemia Skin rash, peeling Snuffles Condylomata Pseudoparalysis Chorioretinitis

Late signs-1st 2 decades Olympian brow Higoumenakis sign Saber shin Hutchison’s teeth, Mulberry

molars Saddle nose, Rhagades Juvenile paresis Juvenile tabes Blindness Cluttons joints

Syphilis - diagnosis

Whom to investigate:

1. All symptomatic babies

2. Asymptomatic babies whose mother is a suspect

NONSPECIFIC TESTS:VDRL – baby’s titre 4 times that of mother, RPR

SPECIFIC TESTS: FTA-abs, MHA-TP, TPI CSF VDRL : marker of neurosyphoilis

Syphilis - treatment Whom to treat?1. Babies of untreated/partially treated mothers2. Relapse/reinfection in mother3. Physical evidence of active disease in the baby4. Presence of radiological evidence5. CSF VDRL found +ve6. Baby’s VDRL titre >4 times of mother What to treat with?1. Aq. C.penicillin G 1 lac u /kg/day in q12hX 7 days followed by q8h X 7 days2. Neurosyphilis: 2 lac u /kg/day q6h X 14 days Prevention: routine antenatal screening

prevention of STDs

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