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Neonatal Sepsis3

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