Neonatal SepticemiaNeonatal Septicemia
Li Yijuan
First Affiliated Hospital
SUMS
Will They Have Good Future ???
Objectives
What will I learn?
Etiologies and risk factors
Symptoms
Diagnosis
Treatment
Introduction
Common -20% of VLBW has sepsis
-In term 0.1%-Inter-institution difference 11-32% (NICHD net work)
Serious-mortality is 3-5 times more for infant with sepsis in NICU
What is Neonatal Sepsis?
Neonatal Septicemia is a generalized
infection characterized by the proliferation
of organisms in the blood circulation during
the first month of life.
Some basic definitions
• SIRS(systemic inflammatory response syndrome ) - fever, tachypnoea, tachycardia, abnormal WBC
• Sepsis- systemic response to infection
• Severe sepsis- sepsis with organ dysfunction, hypotension
• Septic shock- severe sepsis with multiorgan
dysfunction
difficult to apply these definitions and a staging
system to the newborn
Pathogen
• Staphylococcus • Escherichia coli• Conditional pathogen • Group B streptococcus
Staphylococcus
E. Coli
• Staphylococcus epidermidis
• Pseudomonas aeruginosa
Klebsiella
• Clostridium perfringens
Group B -hemolytic streptococcus
Route of Infection
• Prenatal infection
• infection during delivery
• postnatal infection
Sepsis Risk Factors
• Prematurity
• Birth weight
– Term 0.1%
– 1,000 -1,500 g 10%
– <1,000 g 35%
– <750 g. 50%
• Delay enteral feeding and Prolonged TPN
I.Risk Factors (maternal and neonatal)A.Major
1.Maternal prolonged Rupture of Membranes >24 hours 2.Intrapartum maternal fever >38 C (>100.4 F) 3.Chorioamnionitis 4.Sustained Fetal Tachycardia >160 beats per minute
B.Minor 1.Intrapartum maternal fever >37.5 C (>99.5 F) 2.Twin Gestation 3.Premature infant (<37 weeks) 4.Maternal Leukocytosis (White Blood Cell count >15000) 5.Rupture of Membranes > 12 hours 6.Tachypnea (<1 hour) 7.Maternal Group B Streptococcus Colonization 8.Low APGAR (<5 at 1 minute) 9.Low birth weight (<1500 grams) 10.Foul lochia
What makes a neonate’s immune system susceptible to sepsis?
Maturity
Immaturity
or
You’re Right!!!!
The immaturity of a neonate’s immune system makes them MORE SUSCEPTIBLE to sepsis.
Why are newborns so vulnerable to infection?
Non-specific immunity
Specific immunity
IMMUNE SYSTEM
Neutrophils –Qualitative
and quantitative
Complement andimmunoglobulinlevels decreased
T cells- antigenically naïve
limited cytokineproduction
Why are newborns so vulnerable to infection?
• Poor skin barrier
• Umbilical stump
• Poor blood-brain barrier
Classification
• Early onset sepsis (EOS):– bacteria acquired before and during delivery– 5-7/1000 live birth– 1.5% of VLBW infants had EOS (intrapartum
antibiotics)
• Late onset sepsis (LOS): – bacteria acquired after delivery (Nosocomial
or community)– 20% of VLBW infants
Clinical menifestationsClinical menifestationsClinical menifestationsClinical menifestations
EOS LOS
Onset Within 7 days >7 days
Source Prenatal
During delivery
During delivery
Postnatal(nosocomial )
Pathogens G-bacili Staphylococcus;
Opportunitic
Presentation
Mortality
Pneumonia
High
Bacteremia and / or meningitis
Low
Symptoms of Neonatal Sepsis
The symptoms are not concrete and vary widely
Tachypnea Heart Rate Changes
Feeding difficulties
Difficulty Breathing Temperature Instability
Jaundice Irritability
Omphalitis
Bleeding tendencyPoor perfusion
Enlargement of liver and spleen
toxical paralytic ileus
NEC
NEC
dyspnea
Clinical presentation
Early warning signs are often non-specific and subtle
easily confused with non-infective causes (e.g. apnea of prematurity, variation in environmental temperature or
acute exacerbation of chronic lung disease)
clinical course alarmingly fulminant
septic shock + DIC
death
Non-specific, multi- systems/organs involved
Clinical manifestationClinical manifestation
The symptoms are so broad , non-specific,
and acute deterioration,
How to make a diagnosis as early as possible ?
Laboratory studies
• Evidence for inflammation
• Evidence for infection
• Evidence for multiorgan system disease
Laboratory Examination: CBC
• WBC<5×109/L or WBC>20× 109/L
• I/T≥0.2 , toxic granules
• thrombocytopenia <100×109/L
Reference values for neutrophilic cells
Manroe BL, J Pediatr 1979;95:89-98.
Total neutrophils
Immature neutrophil
I/T ratio
Lab examination:CRP
• CRP
• α1-AG
• α1-AT
Lab Exam: Organism detection
blood culture
culture of body fluid and secretion
plasma brown layer smear
--Detection of antigen: usually for antibody
of GBS or E coli in CSF, blood and urine
--Molecular biochemical method PCR
Summary
Is there a diagnostic marker
for neonatal sepsis?
Great answer! You’re correct!
• There is NOT a specific diagnostic marker, only determinants of infection
Summary
The best approach for diagnosis of systemic bacterial infection:
• use of multiple markers (e.g. CRP, IL-6, TNF, CD64), and
• serial measurements
Diagnosis • history
–high risk factors• clinical manifestation
--nonspecific S/S• lab results
- abnormal blood routine,
CRP, positive culture
or detection of organisms
Therapy
• Infection should be the first thought
when an infant has symptoms
• Aggressive treatment should begin before
the diagnosis is confirmed.
• Therapy can be discontinued if sepsis is
excluded
Treatment
Antibiotics therapy
management of complications
supporting therapy
Clearance of infectious focus
Immunotherapy
Antibiotic therapy
• using antibiotics as early as possible
• choose antibiotics according to drug sensitivity
• giving drugs intravenously
• combine effective drugs to make synergism
• enough therapeutic course
• consider the possible side effects
Dosages of antibiotics for newborns
Supporting therapy
• Nursing care
--warm environment
--oxygen supply
• correction of acidosis and electrolyte
disturbance
• fluid , glucose and nutrition balance
Management of complications
• Shock
• DIC
• Cerebral edema
• Pulmonary hemorrhage
Immunotherapy
• IVIG
• Exchange transfusion
• Granulocyte transfusion , G-CSF
• Platelet transfusion
Questions
• Could prophylatic IVIG reduce the
morbidity and mortality of neonatal
sepsis?
• Might prophylatic IVIG interfere the
development of the neonatal IM
system?
Thank you for your attentionThank you for your attention