Neonatal Sepsis3

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Neonatal Sepsis3

  1. 1. NEONATAL SEPSIS Dr. L. Manglem Singh Paediatrician, J. N. Hospital, Porompat Imphal, Manipur.
  2. 2. <ul><li>Neonatal Sepsis </li></ul><ul><li>Clinical syndrome of bacteraemia </li></ul><ul><li>characterized by systemic signs and symptoms of </li></ul><ul><li>infection in the first four weeks of life </li></ul>
  3. 3. <ul><li>Early vs Late onset sepsis </li></ul><ul><li>Early onset Late onset </li></ul><ul><li>Age <72 hours >72 hours </li></ul><ul><li>Risk factor Prematurity Prematurity </li></ul><ul><li>Amnionitis, </li></ul><ul><li>Maternal infection </li></ul><ul><li>Source Maternal genital Environmental </li></ul><ul><li>tract (nosocomial) </li></ul><ul><li>Presentation Fulminant slowly progressive </li></ul><ul><li>Multisystem focal </li></ul><ul><li>Pneumonia frequent Meningitis frequent </li></ul><ul><li>Mortality 5-50% 10-15% </li></ul>
  4. 4. <ul><li>Natural course of sepsis </li></ul><ul><li>Bacteria </li></ul><ul><li>Focal infection Bacteraemia </li></ul><ul><li>sepsis </li></ul><ul><li>Sepsis syndrome </li></ul><ul><li>Early septic shock </li></ul><ul><li>Refractory septic shock </li></ul><ul><li>MODS </li></ul><ul><li>DEATH </li></ul>
  5. 5. <ul><li>Incidence </li></ul><ul><li>In India </li></ul><ul><li>- 3.9 % of all imtramural births </li></ul><ul><li>- 20 – 30 % develop meningitis </li></ul><ul><li>In developed countries </li></ul><ul><li>- 1 in 1000 live births - Term </li></ul><ul><li>- 4 in 1000 live births - Preterm </li></ul><ul><li>- 300 in 1000 VLBW babies </li></ul>
  6. 6. Etiology <ul><li>Escherichia coli </li></ul><ul><li>Staphylococcus aureus </li></ul><ul><li>Klebshiella pneumonae </li></ul>
  7. 7. <ul><li>Risk Factors associated with Neonatal Sepsis </li></ul><ul><li>Maternal Risk Factors </li></ul><ul><li>1. Intrapartum Maternal Infection </li></ul><ul><li>- Purulent / foul smelling liquor </li></ul><ul><li>- Fever (>38 0 C) </li></ul><ul><li>- Leucytosis (WBC >18000 / mm 3 ) </li></ul><ul><li>2. Premature rupture of membranes </li></ul><ul><li>3. Prolonged rupture of membranes > 12 hours </li></ul><ul><li>4. Premature onset of labour (<37 weeks </li></ul><ul><li>5. Maternal UTI </li></ul>
  8. 8. <ul><li>Neonatal Risk factors </li></ul><ul><li>1. Low Birth Weight Baby </li></ul><ul><li>2. Perinatal asphyxia </li></ul><ul><li>3. Male gender </li></ul>
  9. 9. <ul><li>Symptoms of Neonatal Sepsis </li></ul><ul><li>CNS </li></ul><ul><li>Lethargy, Refusal to suckle, Limp, Not arousable, </li></ul><ul><li>poor or high pitch cry, Irritable, Seizures </li></ul><ul><li>CVS </li></ul><ul><li>Pallor, Cyanosis, Cold and clammy skin </li></ul><ul><li>Respiratory </li></ul><ul><li>Tachypnoea, Apnoea, Grunt, Retractions </li></ul>
  10. 10. <ul><li>Symptoms of Neonatal Sepsis </li></ul><ul><li>GIT </li></ul><ul><li>Vomiting, Diarrhoea, Abdominal distension </li></ul><ul><li>Haematological </li></ul><ul><li>Bleeding, Jaundice </li></ul><ul><li>Skin </li></ul><ul><li>Rashes, Purpura, Pustules </li></ul>
  11. 11. <ul><li>Laboratory Diagnosis of Neonatal Sepsis </li></ul><ul><li>1. Direct methods </li></ul><ul><li>- Blood culture </li></ul><ul><li>- CSF culture </li></ul><ul><li>- Urine culture </li></ul><ul><li>2. Indirect methods </li></ul><ul><li>- Total leucocyte count </li></ul><ul><li>- Absolute neutrophil count </li></ul><ul><li>- Total immature neutrophils </li></ul><ul><li>- Immature to total neutrophols </li></ul><ul><li>- Neutrophil Morphology </li></ul><ul><li>- Platelet count </li></ul><ul><li>- Micro ESR </li></ul><ul><li>- Acute phase reactants </li></ul><ul><li>- Buffy coat examination </li></ul><ul><li>- Smear of gastric aspirate / External ear canal fluid </li></ul><ul><li>- C3d </li></ul>
  12. 12. <ul><li>SEPSIS SCREEN </li></ul><ul><li>At Birth </li></ul><ul><li>Major risk factors </li></ul><ul><li>1. Rupture of membranes > 24 hours </li></ul><ul><li>2. Maternal intrapartum fever > 100.4 0 F </li></ul><ul><li>3. Chorioamninitis </li></ul><ul><li>Minor risk factors </li></ul><ul><li>1. Rupture of membrane > 12 hours </li></ul><ul><li>2. Maternal intrapartum fever > 99.5 0 F </li></ul><ul><li>3. Maternal WBC > 15000 / mm 3 </li></ul><ul><li>4. Low apgar score(< 5 at 1 min, < 7 at 5 min) </li></ul><ul><li>5. LBW ( < 1500 g ) </li></ul><ul><li>6. Preterm labour ( < 37 weeks) </li></ul>
  13. 13. <ul><li>SEPSIS SCREEN </li></ul><ul><li>1. Leucopenia (TLC < 5000 / mm3) </li></ul><ul><li>2. Neutropenia (ANC <1800 / mm3) </li></ul><ul><li>3. Immature neutrophil to total neutrophil </li></ul><ul><li>( I / T) ratio ( > 0.2) </li></ul><ul><li>4. Micro – ESR ( > 15 mm / 1 st hour ) </li></ul><ul><li>5. CRP - positive </li></ul>
  14. 14. <ul><li>Approach to Neonatal Sepsis </li></ul><ul><li>Antenatal Postnatal </li></ul><ul><li>Mothers with risk factors </li></ul><ul><li>Symptomatic Asymptomatic </li></ul><ul><li>infants infant with risk </li></ul><ul><li>factors </li></ul><ul><li>Term Preterm </li></ul>
  15. 15. <ul><li>Evaluation of symptomatic infant for sepsis </li></ul><ul><li>- Sepsis screen </li></ul><ul><li>- Chest X-ray </li></ul><ul><li>- Lumbar puncture </li></ul><ul><li>- Blood culture </li></ul><ul><li>Begin Antibiotics </li></ul><ul><li>Culture positive No risk factors for sepsis </li></ul><ul><li>Presence of focal infection Culture negative </li></ul><ul><li>Sepsis screen positive Sepsis screen negative </li></ul><ul><li>LP abnormal Symptoms resolve by 24 hrs </li></ul><ul><li>Symptoms persists 72 hrs </li></ul><ul><li>Treat pneumonia 7-10 days Treat for 48-72 hrs </li></ul><ul><li>Septicaemia 10-14 days and discharge </li></ul><ul><li>Meningitis 14-21 days </li></ul>
  16. 16. <ul><li>Evaluation of asymptomatic infant for sepsis </li></ul><ul><li>Sepsis screen </li></ul><ul><li>Sepsis screen Sepsis screen Blood culture, LP </li></ul><ul><li>negative positive </li></ul><ul><li>Begin Antibiotics </li></ul><ul><li>Observe for 48-72 hrs Culture positive Culture negative </li></ul><ul><li>and discharge LP abnormal LP normal </li></ul><ul><li>Treat septicaemia 10-14 days Treat for 48-72 hr </li></ul><ul><li>Meningitis for 14-21 days and discharge </li></ul>
  17. 17. <ul><li>Supportive Care </li></ul><ul><li>- Keep the neonate warm </li></ul><ul><li>- Start IV Fluid, Infuse 10% Dextrose 2ml / Kg </li></ul><ul><li>stat to maintain normoglycaemia </li></ul><ul><li>- Maintain fluid and electrolyte balance and </li></ul><ul><li>tissue perfusion </li></ul><ul><li>If CRT > 3 sec infuse 10 ml / Kg normal </li></ul><ul><li>saline </li></ul>
  18. 18. <ul><li>Supportive Care </li></ul><ul><li>- Avoid enteral feed, if sick </li></ul><ul><li>- Start oxygen by hood, if cyanosed </li></ul><ul><li>and support breathing </li></ul><ul><li>- Consider exchange blood transfusion, </li></ul><ul><li>if there is sclerema, DIC, Neutropenia </li></ul>
  19. 19. <ul><li>Choice of Antibiotics </li></ul><ul><li>Pneumonia or Sepsis </li></ul><ul><li>Penicillin + Aminoglycoside </li></ul><ul><li>(Ampicillin or Cloxacillin) (Gentamicin or Amikacin) </li></ul><ul><li>Meningitis </li></ul><ul><li>Ampicillin + Gentamicin </li></ul><ul><li>or </li></ul><ul><li>Cefotaxime + Gentamicin or Amikacin </li></ul>
  20. 20. <ul><li>Superficial Infections </li></ul><ul><li>- Pustules - After puncturing, clean with </li></ul><ul><li>betadine and apply antimicrobial </li></ul><ul><li>- Conjunctivitis- Chloramphenicol eye drops </li></ul><ul><li>- Oral thrush - Local application of Nystatin </li></ul><ul><li>or Clotrimazole </li></ul>
  21. 21. <ul><li>Prevention of Infection </li></ul><ul><li>- Exclusive breastfeeding </li></ul><ul><li>- Keep cord dry </li></ul><ul><li>- Hand washing by care givers </li></ul><ul><li>- Hygiene of Baby </li></ul><ul><li>- No unnecessary intervention </li></ul><ul><li>- Better management of IV Lines </li></ul><ul><li>- Disinfection of Equipments </li></ul>
  22. 22. <ul><li>Hand Washing </li></ul><ul><li>- Single most important means of </li></ul><ul><li>preventing nosocomial infections </li></ul><ul><li>- Very Simple </li></ul><ul><li>- Cheap </li></ul>
  23. 23. <ul><li>Hand Washing </li></ul><ul><li>- Two minutes, hand washing to be done </li></ul><ul><li>before entering baby care area </li></ul><ul><li>- 10 seconds hand washing to be done before </li></ul><ul><li>and after touching every baby, and after </li></ul><ul><li>touching unsterile surfaces and fomites </li></ul>
  24. 24. <ul><li>Steps of effective hand washing </li></ul><ul><li>- Roll sleeves above elbow </li></ul><ul><li>- Remove wrist watch, bangles, ring etc </li></ul><ul><li>- Using plain water and soap, wash parts of the </li></ul><ul><li>hand in the following sequence </li></ul><ul><li>- Palm and fingers (web spaces) </li></ul><ul><li>- Back of hands </li></ul><ul><li>- Fingers and Knuckles </li></ul><ul><li>- Thumbs </li></ul><ul><li>- Finger tips </li></ul><ul><li>- Wrists and forearm up to elbow </li></ul>
  25. 25. <ul><li>Steps of Effective Hand Washing </li></ul><ul><li>- Keep elbow always dependent </li></ul><ul><li>- Close the tap using elbow </li></ul><ul><li>- Dry hands using single use sterile </li></ul><ul><li>paper / napkin </li></ul><ul><li>- Do not keep long or polished nails </li></ul><ul><li>Rinsing hands with alcohol is </li></ul><ul><li>NOT A SUBSTITUTE for PROPER HAND WASHING </li></ul>
  26. 26. <ul><li>Medication preparation </li></ul><ul><li>( Prepare IV fluid under aseptic conditions ) </li></ul><ul><li>- Never use stock solution for flushing </li></ul><ul><li>- Do not use a single bottle for > 24 hrs </li></ul><ul><li>- Label bottle with date / time </li></ul><ul><li>- After seal is removed, use betadine soaked </li></ul><ul><li>sterile cotton to cover the stopper of bottle </li></ul><ul><li>- Use disposable needle each time </li></ul>
  27. 27. <ul><li>Better management of IV Lines </li></ul><ul><li>- Thorough hand washing </li></ul><ul><li>- Wear gloves </li></ul><ul><li>- Use disposable IV cannula </li></ul><ul><li>- Thorough skin preparation </li></ul><ul><li>- All IV ports should be wiped with alcohol </li></ul><ul><li>- Early identification of extravasation </li></ul><ul><li>- Avoid unnecessary IV infusion </li></ul>
  28. 28. <ul><li>Conclusion </li></ul><ul><li>- High index of clinical suspicion </li></ul><ul><li>- Look for Lab evidence of sepsis </li></ul><ul><li>- Start parenteral antibiotics (intravenous) </li></ul><ul><li>- Provide supportive care </li></ul><ul><li>- Review culture reports </li></ul><ul><li>- Practise barrier nursing to prevent </li></ul><ul><li>Cross–infection </li></ul>
  29. 29. <ul><li>Thank you </li></ul>

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