NEONATAL SEPSIS - University of BabylonNEONATAL SEPSIS: Definition: A clinical syndrome of systemic illness accompanied by bacteremia occurring in the first month of life, especially

NEONATAL SEPSIS:Definition:

A clinical syndrome of systemic illness accompanied by bacteremia occurring in the first month of life, especially among premature & V.L.B.W. - It usually presents as septicemia, pneumonia, meningitis, arthritis, osteomyelitis & U.T.I., and it is the commonest cause of neonatal mortality.

SOURCE OF INFECTIONS:

- Intra-amniotic infection

(CHORIOAMNIONITIS) is a major risk

factor for neonatal sepsis.

The primary sites of infection are: skin,

nasopharynx, oropharynx, conjunctiva, &

umbilicus.

- Some infections are transmitted

transplacentally (CONGENITAL or

TORCH INFECTIONS).

Neonates are more liable to get

infection because :

1- Immaturity of the immune system.

2- They have low level of complement.

3- Impaired function of neutrophils, monocytes, & macrophages.

4- K.cells (killer cells) have diminished cytotoxic effect.

5- IgM & IgA do not cross the placenta.

TYPES OF SEPSIS:

1.Early Onset Sepsis(EOS):- Usually occurs in the first wk. of life,

characterised by multisystem, fulminant illness with prominent respiratory symptoms caused by group B streptococci (G.B.S.), listeria monocytogenes, & viruses e.g. CMV.

- 90% of cases presents in the first 24 hr. as respiratory distress which proceeds to respiratory failure.

- Pneumonia is commonest disease.

2.Late Onset Sepsis:

- It usually presents after the first wk.

- Commonly presents as meningitis.

- G.B.S. is the commonest organism

but Listeria monocytogenes accounts

for up to 20%.

3.Nosocomial Infection:

- Usually occurs in the N.I.C.U. & in ill

infants.

- It depends on N.I.C.U. environment,

invasive monitoring and technique.

- Common organisms are staphylococcus

epidermidis, Gram –ve bacteria(e.g.E.coli,

(pseudomonas,klebsiella,proteus) & fungi.

Risk factors for neonatal sepsis:

1. Prematurity.

2. Prolonged rupture of membranes (> 24 hr.).

3. Maternal fever (> 38c).

4. Maternal U.T.I. or genital infection.

5. Meconium stained or foul smelling amniotic fluid.

6. Multiple gestation.

7. Resuscitation at birth with low

APGAR ( < 6 at 1,5 minutes).

8. Invasive procedures.

9. Artificial feeding.

CLINICAL PRESENTATION :

1- Reluctance to feed.

2- Respiratory distress, grunting & apnea.

3- Lethargy, decreased or no movements &

neonatal reflexes.

4- Hypo or hyperthermia (only 50% of

infected neonates have high temp.).

5- Vomiting, diarrhea, abdominal distension.

6- skin rash, petechiae, purpura, skin mottling (cutis murmorata), ecthymagangrenosum (deep ulcers with ecchymotic margins commonly seen in klebsiella infection), impetigo, cellulitis, omphalitis.

7- Poor peripheral perfusion & delayed capillary refill ( > 2 seconds).

8- Hypoglycemia.

9- Sclerema, Edema.10- Hepatosplenomegaly, jaundice.

11- Convulsions, bulging anterior fontanel.

30% of women have asymptomatic G.B.S. colonization.

Differential Diagnosis:1. R.D.S.

2. Metabolic disorders.

3. Perinatal asphyxia.

4. Intracranial hemorrhage.

5. Hypoplastic left heart syndrome.

6.Inbornerrorsofmetabolism.So a high index of suspicion is the corner stone for diagnosis of sepsis because clinical symptoms are non-specific.

LAB STUDIES:

1.Complete Blood Picture:

a) Low platelet count(

5. Increased procalcitonin level ( produced

by hepatocytes & monocytes). 6.

P.C.R. 7.

Imaging studies ( CXR, ultrasound, CT,

MRI). 8.

Cord Interleukin 6&8 measurements

are predictive of sepsis.

9.Elevated IgM level (in congenital

infections).

Indications of Lumbar Puncture :

1- Infants with +ve blood culture.

2- Clinical & Lab.data suggestive of

bacteremia.

3- No response or deterioration while on

antimicrobial tratment.

TREATMENT:

-Early treatment is very

important.

No delay is made

waiting for Lab. results.

BUT REMEMBER THAT:

prolonged empirical Rx (≥5 days) with broad-

spectrum antibiotics for preterm neonates is

associated with higher risks of late onset

sepsis, N.E.C., & death, so

antimicrobial therapy should be discontinued at

48 hr. if clinical probability of sepsis is low &

CRP remains normal.

TREATMENT :1- Antibiotics should be given by

I.V. route.

Duration of Rx:

.clinical sepsis (based on clinical

suspicion) : 7-10 days.

.meningitis: 14-21 days.

.Osteomyelitis: 4-6 weeks.

CHOICE OF ANTIBIOTICS:

A combination of ampicillin & an

aminoglycoside (e.g. gentamicin) or

3rd. generation cephalosporin

(e.g.cephotaxime) is generally used as

initial therapy.

-Ceftriaxone is contraindicated in neonates

because it is highly protein bound and may

displace bilirubin, leading to a risk of

kernicterus. -Metronidazole for

anaerobic infections (for 7-10days).

2- Granulocyte transfusion. 3- Granulocyte macrophage colony stimulating factor (GM-CSF) and Granulocyte colony stimulating factor (G-CSF):are glycoproteins that stimulate proliferation & differentiation of neutrophil precursors & activate mature neutrophils.

4- Supportive care (incubator, O2, i.v.fluid

& electrolytes, dopamine,TPN, IPPV,

vit.K).

5- Pentoxiphylline: a xanthine derivative

which inhibits TNF production &

reduces tissue

injury. 6-

I.V.Immunoglobulin: which promote host

defences by multiple mechanisms.

Prevention of Neonatal Sepsis:

1- Breast feeding.

2- Hand washing by care givers.

3- Tetanus immunization of mothers.

4- Umbilical stump should be kept

clean.

5- Keep interventions as low as

possible.

•6- Intrapartum Rx of infected mothers with i.v. antibiotics (4hr.before delivery) for prevention of GBS infections.

7- Avoid overcrowding in NICU.

8- Good ventilation. 10- No prophylactic antibiotics for

nosocomial infections.

Complications:1.Septic emboli.

2.Abscesses.

3.Septic arthritis.

4.Osteomyelitis.

5.Septic shock.

6.DIC.

7.Meningitis( in 1/3 rd of cases).

8.Mortality is about 50% .