Neonatology: Neonatal Septicemia. Lecture points Morbidity and mortality The compromised host of the neonates in immunology Pathogens for clinical consideration.

Neonatology:

Neonatal Septicemia

Lecture points

• Morbidity and mortality• The compromised host of the neonates in immunology• Pathogens for clinical consideration• Clinical manifestation• Clinical Management

Incidence

• 1% ～ 10%, in live birth

• 15-20%, in VLBW

Incidence

0

5

10

15

20

25

‰

0

5

10

15

20

25

‰

Gross incidence Comparison: US and developing countries

Neonatal Septicemia

5.30%

10.30%

3.10%

0%

3%

6%

9%

12%

15%

USA Preterm Full

Death rate: US

Neonatal Septicemia

Death rate ： developing countries

0%

2%

4%

6%

8%

LONS 7.5%

0%

5%

10%

15%

20%

death rate: 9.8%~12%

• Immature development in body defense

• Imperfect function

• Less experience of exposure to environment and pathogens

• Affected by maternal antibodies

Immunological features in neonates

Non-specific Immune: • Poor barriers function• Undeveloped complement activation capacity • Relative fewer neutrophil, Immature Functio

n• Lower ILs, lower level of cytokines

Immunological features in Neonates

Specific Immune: • Quantities and quality of Ig G, A, M• T, B cell: quantities, quality and their function

Immunological features in Neonates

Pathogens

• Domestic:– Staphylococcus: most commonly seen– Escherichia coli, etc. – G- bacillus

• US:– GBS: the leading pathogen during 1970’s– Escherichia coli: the leading pathogen

during 1990’s

Pathogenic Changes

0

1

2

3

4

5

6

7

8

GBS

E.coli.

‰

EONS: Changes by G+ vs. G-

Early 1990’s Late 1990’s

0%

5%

10%

15%

20%

91-93 96-00

year

any

G+

G-GBS

E.coli

Pathogenic Changes

Relevant factors of pathogenic changes

• Change of colonized pathogens in maternal birth canal • GBS Screening • Preventive antibiotic therapy used during pre partum

• Ampicilline for the mother with GBS positive : pre partum and Intro-partum GBS Septicemia Efficacy ： around 70% （ vs. control P < 0.0001 ）

Pathogens based on the types in developed country

• EONS ：– E. coli– Listeria monocytoge

nes, Pseudomonas– Meningococcus– Enterococcus and G

BS

• LONS ：– Coagulase-negative

Staphylococcus– Haemophilus influen

za bacillus– Other pathogens

Pathogens based on the types in developed country

E.coli. 27%

Staph 40%

Klebsiella 15%

GBS <10%

Others >8%

LONS (48 hours after birth) Mainly: G+ Coagulase-negative Staphylococcus Partly reported ： Staphylococcus epidermidis, GBS and E. coli

EONS (within 24-48 hours after birth)G+ = G-

G+ ： mainly Klebsiella pneumoniae and E. coliG- ： Enterococcus commonly seen

VEONS (within 24 hours after birth)Klebsiella 、 E. coli 、 Enterococcus

Pathogens based on the types in developing country

VEONS42%

EONS40%

LONS7% Others

11%

Early onset dominant Related with the maternal and the intro-partum high risk factors

Pathogens based on the types in developing country

Pathogens isolated in China

0

5

10

15

20

25

30

35

40

45

0-3d(671) 4-7d(458) 8-28d(1849)

CNS金葡菌E.col i肠杆菌假单胞菌

main isolates from blood culture bsed on the ages: n=671/458/1849

临床儿科杂志： 2002-2 浙江大学附属儿童医院资料

Pathogens isolated in China

0

5

10

15

20

25

30

表葡 腐生葡 E. col i 金葡菌 克雷伯 不动杆菌

中华儿科杂志 01-6 ；重庆儿科医院资料

Domestic data ： main isolates: n=815

main isolates account for during different periods: n=436

0%10%20%30%40%50%60%70%80%90%

100%

92-94 95-96 99-00

G+

staph

Staphylococcusepidermidisother CNS

临床儿科杂志 02-5 ：深圳市人民医院儿科资料

Pathogens isolated in China

Pathogens isolated in China

0%10%20%30%40%50%60%70%80%90%

100%

92-94 95-96 99-00

G-其它不动杆菌假单胞菌克雷白杆菌沙门氏菌E. col i

HF

G+其它链球菌肠球菌

CNS其它表葡菌金葡菌

临床儿科杂志 02-5 ：深圳市人民医院儿科资料

main isolates account for during different periods: n=436

Pathogens isolated in China

0.00%

20.00%

40.00%

60.00%

80.00%

100.00%

1989-1991 1999-2001

肠杆菌棒壮杆菌Ecol i芽胞杆菌CNS金葡菌

main isolates account for during different periods: n=606/475

临床儿科杂志： 2002-2 哈尔滨儿童医院资料

The path of Infection

Path:1. Intrauterine infection

2. Intro-partum infection

3. Post delivering infection

• Maternal intro-partum fever (OR=4.1 CI=1.2-13.4)

• Repeated Vaginal examinations (OR=2.9 CI=1.1-8.0)

• Among GBS Sepsis, Dystocia and maternal fever account for 49%

• Prolonged membrane rupture ≥18 hour （ 79% ）• Prematures and LBW

• Later onset sepsis: PDA, Long time of Intravascular catheter, various of invasive procedure, BPD

Risk factors of sepsis occurrence

Clinical manifestations

General ：– Anorexia– Less Crying– Fewer physical activi

ties– Lower temperature

or fever – Poor weighting gain– Persistent Jaundice

Focal:– Omphalitis

– Skin infection

– Blepharitis (eyes)

– Otitis media

– Paronychia (nails)

Clinical manifestations

Toxic:– Shock– Hepatosplenomegaly– Skin deposition point– Distension– Anemia

Complication:– Meningitis– Pneumonia – Peritonitis– Urinary Tract Infectio

n– Scleredema– DIC– Toxic myocarditis

Laboratories and investigation aids

• Peripheral whole blood test• Blood culture • Others:

– CRP/ PCT– Smear of WBC: check bacterial – CSF– Urine

• CXR

Clinical Management

Antibiotic therapy• Selection based on the pathogen isolated

• Early, Adequate dose, IV

• Duration: – 2 weeks for G+, 3 weeks for G-. – Longer duration for meningitis and severe

Supportive therapy

– Dehydration– Correct metabolic acidosis– Maintenance of electrolyte and Acid-base

balance– Enough energy supply– Keep warm– Correct hypoxemia– Immunological therapy: IVIG

Clinical Management

Complication treatment– Shock– DIC– Scleredema– Respiratory failure – Conversion

– Jaundice– Focal lesion

Clinical Management

Thanks for listening

Questions please?