Neonatal Infection 2005

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Neonatal Infection 2005

  1. 1. Neonatal Infections May 2005 Dr Patricia Fenton Sheffield Children’s Hospital
  2. 2. Neonatal Infections <ul><li>Hazard analysis at critical control point </li></ul><ul><li>A baby production line </li></ul><ul><li>Uterus to push chair </li></ul>
  3. 3. The Bad News Is….. <ul><li>No </li></ul><ul><li>Pictures </li></ul>
  4. 4. The Good News Is…. <ul><li>994 out of every 1000 infants born in the UK survive </li></ul>
  5. 5. Some Definitions <ul><li>Infant - <1 year </li></ul><ul><li>Neonate - < I month </li></ul><ul><li>“ early onset” - < 7 days </li></ul>
  6. 6. Infant Deaths 93-97 (Number) <ul><li>E and W figures </li></ul><ul><li>Neonates account for 67% of deaths </li></ul><ul><li>Infection is NOT a major cause of neonatal death. </li></ul>
  7. 7. A Hazardous Journey <ul><li>The uterus: Listeria monocytogenes </li></ul><ul><li>The birth canal: group B streptococcus </li></ul><ul><li>The unit: Acinetobacter baumanii </li></ul><ul><li>Devices: CNS </li></ul><ul><li>The attendants: Staph aureus </li></ul>
  8. 8. Three Barriers to Infection NORMAL FLORA SKIN AND MUCOUS MEMBRANES IMMUNITY
  9. 9. Impaired Barriers <ul><li>Thin skin </li></ul><ul><li>Raw umbilicus </li></ul><ul><li>Invasive devices </li></ul>
  10. 10. Small/premature = <ul><li>Poor antibody response </li></ul><ul><li>Poor neutrophil response </li></ul><ul><li>Poor complement activation </li></ul><ul><li>Impaired macrophage activity </li></ul><ul><li>Poor T cell function </li></ul><ul><li>Reduced placental IgG </li></ul>
  11. 11. Clinical Presentations <ul><li>Not breathing well </li></ul><ul><li>Not feeding well </li></ul><ul><li>Not looking well </li></ul><ul><li>lethargic irritable mottled </li></ul><ul><li>Fever and tachycardia </li></ul><ul><li>Seizures </li></ul><ul><li>AND NOT A BLOOD TEST OR XRAY! </li></ul>
  12. 12. Listeria monocytogenes <ul><li>1-3 cases per million per year E&W </li></ul><ul><li>17 pregnancy associated cases 2001 </li></ul><ul><li>>300 pregnancy assoc. 87-89 </li></ul><ul><li>Soft cheese, paté and chilled meals </li></ul><ul><li>All animals </li></ul><ul><li>5% humans in bowel </li></ul>
  13. 13. Listeria - an interesting organism <ul><li>G + rod </li></ul><ul><li>Flagellae-RT not BT </li></ul><ul><li>Tumbling motility </li></ul><ul><li>Haemolytic BA </li></ul><ul><li>Invasin (IC) </li></ul><ul><li>Actin tails </li></ul><ul><li>Listerioloysin O </li></ul>
  14. 14. Log10 bacteria per ml
  15. 15. Disease Spectrum <ul><li>Influenza like illness (maternal) </li></ul><ul><li>Sepsis with stillbirth </li></ul><ul><li>Neonatal sepsis/meningitis </li></ul><ul><li>Sepsis/meningitis in impaired immunity (at any age) </li></ul>
  16. 16. Treatment, Outcome and Control <ul><li>Ampicillin or amoxycillin </li></ul><ul><li>Plus gentamicin </li></ul><ul><li>One third fatal </li></ul><ul><li>Avoidance, food quality measures, high level of suspicion, early treatment </li></ul>
  17. 17. Early Onset GBS Disease <ul><li>376 cases in 2001 </li></ul><ul><li>39 died </li></ul><ul><li>Important because: </li></ul><ul><li>Identified risk factors </li></ul><ul><li>Preventable </li></ul>
  18. 18. Risk Factors <ul><li>Previous baby affected by GBS </li></ul><ul><li>GBS in urine at any time this pregnancy </li></ul><ul><li>Preterm labour </li></ul><ul><li>Prolonged ROM </li></ul><ul><li>Fever in labour </li></ul><ul><li>(RCOG guidelines 2003) </li></ul>
  19. 19. Screening Based Strategy <ul><li>27% carry it (rectal plus vaginal swabs) </li></ul><ul><li>Antibiotic prophylaxis 86% reduction </li></ul><ul><li>Treat 1000, prevent 1.4 </li></ul>
  20. 20. Risk Factor Strategy <ul><li>25% women have one or more risk </li></ul><ul><li>Antibiotic prophylaxis 69% reduction </li></ul><ul><li>Treat 1000, prevent 2 </li></ul>
  21. 21. The Disease <ul><li>Early onset </li></ul><ul><li>Low apgar </li></ul><ul><li>Sepsis </li></ul><ul><li>Pneumonia </li></ul><ul><li>GBS causes 70% early onset sepsis </li></ul><ul><li>Low birth weight </li></ul>
  22. 22. Prevention <ul><li>Choose your mother carefully (IgG) </li></ul><ul><li>Be big (mortality 6% vs. 18%) </li></ul><ul><li>Penicillin AT ONSET OF LABOUR </li></ul>
  23. 23. Christmas Day HH <ul><li>Premature 35/40 </li></ul><ul><li>No ANC </li></ul><ul><li>Septic, ventilated </li></ul><ul><li>Extubated day 11 </li></ul><ul><li>Home “to die” </li></ul><ul><li>BUT…. </li></ul>
  24. 24. The Unit <ul><li>24 cots (2x6 bedded 1x12 bedded) </li></ul><ul><li>Zero to two cases per year for 5 years </li></ul><ul><li>4 month period 11 cases clinical sepsis </li></ul><ul><li>All cases in one 6 bedded ward area </li></ul>
  25. 25. The Bug <ul><li>Acinetobacter baumannii </li></ul><ul><li>Gram negative cocco-bacillus </li></ul><ul><li>Water-dwelling saprophyte </li></ul><ul><li>Long survival on dry surfaces </li></ul><ul><li>Mattresses, air con, ventilators </li></ul><ul><li>Up to 25% normal human skin flora </li></ul><ul><li>Dissemination via hands? </li></ul>
  26. 26. What Happened Next? <ul><li>Cultured everything. </li></ul>
  27. 27. Results? <ul><li>Nothing </li></ul><ul><li>Followed each baby and everything that happened to them </li></ul>
  28. 28. And they found <ul><li>Hydrocolloid dressings-large sheets </li></ul><ul><li>Cut and stored </li></ul><ul><li>Used on skin </li></ul><ul><li>CULTURE POSITIVE OUTBREAK STRAIN </li></ul>
  29. 29. What happened next? <ul><li>Practice stopped </li></ul><ul><li>Outbreak ended </li></ul><ul><li>3 babies died </li></ul>
  30. 30. Lessons Learnt <ul><li>A knowledge of background infection rates useful (none to 11) </li></ul><ul><li>Susceptible patients are just that </li></ul><ul><li>Plastic wallets make good incubators </li></ul>
  31. 31. Devices <ul><li>Initial response </li></ul><ul><li>Getting worse </li></ul><ul><li>Central line in situ </li></ul><ul><li>?CNS </li></ul>
  32. 32. Coagulase negative staphylococci <ul><li>Gram positive cocci </li></ul><ul><li>Normal skin flora </li></ul><ul><li>Low grade pathogen in normal host </li></ul><ul><li>Hydrophobic cell surface (adheres) </li></ul><ul><li>Polysaccharide production - biofilm </li></ul><ul><li>Neonatal infections </li></ul>
  33. 33. Neonatal Unit B/C <ul><li>CNS 234 </li></ul><ul><li>Stau 17 </li></ul><ul><li>E.coli 19 </li></ul><ul><li>GNB’s 32 </li></ul><ul><li>GBS 18 </li></ul>
  34. 34. Attendants <ul><li>6 week period </li></ul><ul><li>4 blistered babies </li></ul><ul><li>Early discharge </li></ul><ul><li>14 more identified </li></ul><ul><li>Staph aureus </li></ul><ul><li>Phage type 3A/3C </li></ul><ul><li>Exfoliative toxin A </li></ul>
  35. 35. Outbreak Control <ul><li>Swabs of all staff handling newborns </li></ul><ul><li>Check all hands </li></ul><ul><li>One individual handled 17/18 affected </li></ul><ul><li>Epidemic strain from nose, axilla, peri </li></ul><ul><li>All other staff negative </li></ul><ul><li>Treatment of carrier ended outbreak </li></ul>
  36. 36. Staphylococcus aureus <ul><li>Looks like CNS and.. </li></ul><ul><li>Normal flora (30% adults) but.. </li></ul><ul><li>Highly pathogenic </li></ul><ul><li>Exfoliative toxin A - SSSS </li></ul><ul><li>Potential for cross infection </li></ul><ul><li>Treated with flucloxacillin </li></ul>
  37. 37. Control Measures <ul><li>Wash hands </li></ul><ul><li>and </li></ul><ul><li>check hands </li></ul>
  38. 38. Conclusions <ul><li>Infection: significant hazard to neonate </li></ul><ul><li>Journey womb to push chair </li></ul><ul><li>Bacteria for every occasion </li></ul><ul><li>Smaller is frailer </li></ul><ul><li>Never give up on a neonate </li></ul>
  39. 39. Our Aim at SCH <ul><li>Family focused service </li></ul><ul><li>Putting the needs and welfare </li></ul><ul><li>of children first </li></ul>

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