Neonatal Sepsis

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Neonatal Sepsis

  1. 1. -C.S.N.Vittal Vijayawada
  2. 2. Bacterial Sepsis in Neonate Definition : Clinical syndrome of infection with bacterimia in first month of life. • May get predominantly localized to lung (Pneumonia) • May be localized to meninges (meningitis)
  3. 3. Bacterial Sepsis in Neonate Incidence : 24 / 1000 live births Single most important cause of neonatal deaths in the community (>50%)
  4. 4. Bacterial Sepsis in Neonate Patterns Late Onset Early Onset •Within 72 hrs of birth • Complicated pregnancy + • Maternal Genital tract • Symptoms beyond 72 hrs of birth • Complicated pregnancy + • Fulminant course • Maternal Genital tract / Environmental • Pneumonia • Slower progression • 5-50 % mortality • Meningitis • 2-6 % mortality
  5. 5. Neonatal Sepsis Major Risk Factors • Ruptured membranes > 24 hrs. • Maternal Fever (100.4oF(38oC) • Chorionamnionitis • Sustained fetal heart rate >160/min • Multiple obstetric procedures Minor Risk Factors • Ruptured membranes > 12 hrs. • Foul smelling liquor • Maternal Fever > 99.5oF (37.5oC) • Low APGAR < 5 at 1 min, < 7 at 5 min • Prematurity • Multiple gestation Presence of 1 major or 2 minor risk factors -> High Risk of Sepsis
  6. 6. NNF CRITERIA SUSPECT SEPSIS 1 out of 3 parameters is an indication for antibiotic therapy • PREDISPOSING FACTORS like PROM, Foul smelling liquor, amnionitis, gastric aspirate showing polymorphs 5 / HPF • POSITIVE SEPSIS SCREEN (2/4 parameters) – TLC <5000 per cubic ml – Bandemia 20% – CRP >10 ng per ml – Micro ESR >10mm fall in 1hr • CXR showing Pneumonia
  7. 7. Neonatal Sepsis Pathogenesis • Infection in the birth canal • Colonization of skin, umbilical stump, nasopharynx, conjunctiva, etc. • Transient bacteremia • Invasion of blood stream • Metastatic foci • Meningitis, etc.
  8. 8. Neonatal Sepsis Risk factors for Late onset sepsis (LOS) • Prolonged hospitalization • Prematurity • LBW • Previous antibiotic use • Invasive procedures • Presence of foreign material (ET Tubes/ catheters) • Lack of disposables • Over crowding / understaffing
  9. 9. Neonatal Sepsis Risk factors for Community acquired sepsis • Bottle feeding • Poor hygiene • Poor cord care • Over crowding
  10. 10. Pathogenesis ... • SIRS • CARS • MARS
  11. 11. Infection Systemic Inflammatory Response Syndrome (SIRS) Resp: Tachypnoea Hypoxia PaO2 > 2 SD < 70 mm Hg CVS : Tachycardia > 2 SD Hypothermia < 2 SD or hyperthermia Peripheral Perfusion: Delayed Capillary Filling > 3 Sec. Oliguria < 0.5 ml / kg / hr Lactic acidosis Altered mental status Increased or decreased white blood count:
  12. 12. Infection > SIRS Sepsis – • Systemic response to infection with bacteria : SIRS with hypotension Severe Sepsis – • Sepsis with organ dysfunction, hypoperfusion or hypotension • Changes in mental status, oliguria, hypoxemia or lactic acidosis
  13. 13. Septic shock – Severe Sepsis with persistent hypotension despite adequate fluid resuscitation Multiple Organ Dysfunction Syndrome (MODS) – Presence of altered organ function such that homeostasis can not be maintained without intervention Death
  14. 14. Local Initial insult pro-inflammatory (bacterial, viral response thermal, traumatic) Systemic spillover of proInflammatory mediators Systemic Reaction Local anti-inflammatory response Systemic spillover of antiInflammatory mediators SIRS : Pro CARS : Anti MARS : Mixed C H CV Compromise Homeostasis A Aptosis O MODS S Suppression of immunity
  15. 15. Clinical Features • General : • Skin: – Lethargy, jaundice – Temperature instability • Respiratory – Distress after a period of normalcy – Apnea • GI: – Poor feeding, vomiting, abdominal distention, bilious aspirates – Temperature labiality – Petechial rashes, bleeding from puncture sites – Sclerema • CNS: • – Lethargy, irritability, seizures Metabolic: – Unexplained metabolic acidosis – Hyperglycemia – Hypoglycemia • Features to system involvement
  16. 16. Sepsis Screen • Total neutrophil count : • Immature to total ratio : •Acute Phase Reactions • Micro ESR • C Reactive Protein • Hepatoglobin : : Laboratory Studies < 5000 / mm3 > 0.2 > 15 mm in 1st hour > 10 mg/L • Cultures • Chest X-Ray • Grams Stain of gastric aspirate • Antigen detection methods • Lumbar Puncture
  17. 17. Neonatal Sepsis Total neutrophil count & Immature to total ratio: • TWBC • Tot. neutrophil count : < 5000 / micro liter or >24000 : < 1000 / micro liter ( Normal= 1,750 /µL) • Band / Total Neutrophil : > 0.2 ( Normal = 0.16 in 1st Day, 0.12 after 24 Hrs.) • Platelet Count : < 1 Lakh/mm3 (Normal = 1.5 to 4 Lakhs /mm3) - Increased risk of infection Repeat TWBC & DC at 8 - 12 hrs in a symptomatic neonate may have more predictable value than single record.
  18. 18. Neonatal Sepsis Cultures • Blood • Urine • CSF ( For Late Onset type)] Two positive cultures are more significant
  19. 19. Neonatal Sepsis Chest X-Ray • Persistent focal changes with infiltrative process • Findings similar to RDS in GBS infection
  20. 20. Neonatal Sepsis Acute Phase Reactants - Sepsis Screen Positive CRP ( > 6 mg/ L or 10 times normal) Elevated hepatoglobin level Micro ESR After 14 days of age 15 mm or more for the first hour is abnormal. (Normal ESR = Age in days + 2) If all results are -ve : Probability that infection absent = 99% If all results are +ve : Probability of infection = 90%
  21. 21. Neonatal Sepsis Grams Stain of gastric aspirate Positive Result : If > 5 neutrophils / hpf or Large number of bacteria (esp. Gram+ve cocci) in large clumps and chains Predictive value less
  22. 22. Neonatal Sepsis Antigen detection methods • Latex particle aggulutination assays for GBS and ECK1 • Counter immuno electrophoresis
  23. 23. Neonatal Sepsis Lumbar Puncture • Valuable in symptomatic infants who have risk factors for sepsis. • CSF studies prior to antibiotic therapy is preferable LP in RDS is difficult Interpretation is difficult if LP is traumatic Sometimes meningitis may be present with normal CSF picture
  24. 24. Normal Neonatal CSF TEST TERM PRETERM WBCs (per cm) Polymorphs Up to 30 60% Up to 90 60% Protein (mg/dL) Up to 150 Up to 150 Glucose (mg/dL) 35-120 25-65
  25. 25. Neonatal Sepsis Miscellaneous Investigations • DIC Profile • Culture of catheters/ ET Tubes • Maternal vaginal swab cultures, etc.
  26. 26. Supportive therapy • • • • • • • • • Thermoneutral environment IV Fluids Electrolyte and acid base balance Maintain oxygen saturation Circulatory support Glucose homeostasis Treat anemia with packet Rbc Treat bleeding diathesis with FFP / platelets
  27. 27. Antibiotic Therapy Indications: • • • • • PROM > 12 hrs. Evidence of Chorioannionitis Delivery outside labour room Infants with 1 major or 2 minor risk factors Positive Sepsis Screen
  28. 28. • • • • • • • • • • • • • • • • Sulfa Drugs Folic Acid Analogs The Beta-Lactams Aminoglycosides Tetracyclines Macrolides Lincosamides Streptogramins Fluoroquinolones Polypeptides Rifampin Mupirocin Cycloserine Aminocyclitol Glycopeptides Oxazolidinones Arm a me nt ariu m … and the list is incomplete …
  29. 29. Which one would you choose ?
  30. 30. Factors to be considered in the choice of Antibiotic Gram + ve Gram _ ve Anaerobes
  31. 31. Antibiotic Selection Presumptive therapy directed to most commonly encountered pathogens. 1st Line : Ampi/Sulbactum+Aminoglycoside 2nd Line 2nd gen. Cephalosporins + Aminoglycosides 3rd Line Vancomycin + Cephalosporins Newer antibiotics
  32. 32. er ew fN le o Ro s? r ug d
  33. 33. Antibiotic Evolution
  34. 34. When you can’t decide , you tend to … Resort to “Shotgun Therapy”
  35. 35. Bauer-Kirby Method (Agar gel diffusion method)
  36. 36. Duration of Antibiotic Therapy Culture Positive Sepsis Pyogenic Meningitis - 14 Days - 21 Days / 2 weeks after CSF sterile Culture – ve/ clinically probable sepsis screen +ve:7-10 d. Culture – ve/ clinically probable sepsis screen -ve:5-7 d. Septic Arthritis - 6 Weeks
  37. 37. Immunotherapy • Immunoglobulin : IVIG 500-1000 mg/kg/dose • Specific Immunoglobulins : Anti GBS Ig. • Oral administration of IgA and IgG in NEC • Granulocyte infusions • G – CSF 10 µg/kg/d for 3 days • GM – CSF 10 µg/kg/d for 5 days • Double volume exchange transfusions
  38. 38. Supportive Therapy • Continued Breast Feeding • Nutrition : TPN / Aminoplasma • Fluid / Electrolyte balance • Treatment of acidosis
  39. 39. Preventive Aspects of Neonatal Sepsis • Obstetric Management strategies • Screening based approach • Risk factor approach • Exclusive breast feeding • No prelacteals • Keeping the cord dry • Hand washing by care givers before and after handling the baby (Single most effective measure) • Hygiene of the baby • Avoid unnecessary intravenous fluids, needle pricks etc.
  40. 40. Algorithm for early prevention of GBS Risk Factors Give intrapartum Previous GBS penicillin Preterm delivery Bacteremia Rectal & Vaginal swab c/s. at 35-37 wks. Risk Factors Intrapartum Temp. PROM > 18 hrs No intrapartum prophylaxis needed Give intrapartum penicillin Give intrapartum penicillin

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