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11. Sespsis Targoviste
11. Sespsis Targoviste
11. Sespsis Targoviste
11. Sespsis Targoviste
11. Sespsis Targoviste
11. Sespsis Targoviste
11. Sespsis Targoviste
11. Sespsis Targoviste
11. Sespsis Targoviste
11. Sespsis Targoviste
11. Sespsis Targoviste
11. Sespsis Targoviste
11. Sespsis Targoviste
11. Sespsis Targoviste
11. Sespsis Targoviste
11. Sespsis Targoviste
11. Sespsis Targoviste
11. Sespsis Targoviste
11. Sespsis Targoviste
11. Sespsis Targoviste
11. Sespsis Targoviste
11. Sespsis Targoviste
11. Sespsis Targoviste
11. Sespsis Targoviste
11. Sespsis Targoviste
11. Sespsis Targoviste
11. Sespsis Targoviste
11. Sespsis Targoviste
11. Sespsis Targoviste
11. Sespsis Targoviste
11. Sespsis Targoviste
11. Sespsis Targoviste
11. Sespsis Targoviste
11. Sespsis Targoviste
11. Sespsis Targoviste
11. Sespsis Targoviste
11. Sespsis Targoviste
11. Sespsis Targoviste
11. Sespsis Targoviste
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11. Sespsis Targoviste

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  • 1. <ul><li>Infections of the Newborn : </li></ul><ul><li>Evaluation and Management </li></ul>
  • 2. Menu <ul><li>Background statistics </li></ul><ul><li>Terminology </li></ul><ul><li>Why babies are more vulnerable </li></ul><ul><li>Risk factors </li></ul><ul><li>Clinical signs </li></ul><ul><li>Screening </li></ul><ul><li>Workups </li></ul><ul><li>Treatment </li></ul><ul><li>Aftermath </li></ul><ul><li>Prevention </li></ul><ul><li>Future Trends </li></ul><ul><li>Specific Clinical Entities </li></ul>
  • 3. Background Statistics <ul><li>Neonatal literature says: </li></ul><ul><ul><li>Actual infection rate 1-8/1000 newborns </li></ul></ul><ul><ul><li>LBW infection rate 1-2/100 newborns </li></ul></ul><ul><ul><li>5 infants die from neonatal infection every minute </li></ul></ul><ul><ul><li>4-5 (10%) deaths are due directly to infection but mortality as high as 25% </li></ul></ul><ul><ul><li>Romania – poorly control and not exactly report of the infections </li></ul></ul>
  • 4. Terminology(1) <ul><li>Bacteriemia -presence of viable bacteria in the circulating blood confirmed by culture </li></ul><ul><li>Sepsis -clinical suspicion of infection and evidence of systemic response to infection (tachycardia, tachypnea, hyperthermia, or hypothermia) </li></ul><ul><li>Sepsis syndrome -sepsis plus evidence of altered organ perfusion with at least one of the following: acute changes in mental status, oliguria, elevated blood lactate and hipoxemia </li></ul>
  • 5. Terminology (2) <ul><li>Septic shock- Sepsis syndrome with hypotension that is responsive to IV fluids or pharmacologic intervention </li></ul><ul><li>Refractory septic shock- sepsis syndrome with hypotension that last for more than 1hour and does not respond to IV fluids or pharmacologic intervention and requires vasopressor support </li></ul><ul><li>Multiorgan failure- any combination of DIC, ARDS, acute renal failure, hepatobiliary dysfunction, and CNS dysfunctions </li></ul>
  • 6. Historical Changes in Predominant Infectious Agent <ul><li>Historical Changes in Predominant Infectious Agent </li></ul><ul><li>1930: Group A Strep </li></ul><ul><li>1940: E. coli </li></ul><ul><li>1950: Staph aureus </li></ul><ul><li>1970: Group B Strep </li></ul><ul><li>For reasons which remain unclear neonatal infectons in the developing nations are dominated by Gram-negative and Gram-positive organisms, GBS only accounts 1-8% infants </li></ul>
  • 7. Setting Priorities <ul><li>Newborns are not small children </li></ul><ul><li>Competing perceptions of parents, pediatricians, house-staff, neonatology </li></ul><ul><li>Personal responsibility, hands-on assessments are key </li></ul><ul><li>Remember that 10 babies are worked up for each proven case </li></ul>
  • 8. Neonatal Vulnerability <ul><li>Immature immune system (slow to react, decreased IgG and complement production, poor phagocytosis, poor migration) </li></ul><ul><li>Unavoidable exposure to pathogenic organisms in birth canal </li></ul><ul><li>Peripartum stress </li></ul><ul><li>Invasive procedures </li></ul><ul><li>Exposure to highly resistant nosocomial organisms in NICU </li></ul>
  • 9. Risk Factors <ul><li>PROM (7X) </li></ul><ul><li>Prematurity (7X) </li></ul><ul><li>Maternal fever, chorioamnioitis (4X) </li></ul><ul><li>Perinatal asphyxia (4X) </li></ul><ul><li>Male (2-6X) </li></ul><ul><li>Recent colonization with GBS, Herpes, etc. </li></ul><ul><li>Multiple gestation </li></ul><ul><li>Foul smelling is not necessarily a risk factor - usually anaerobes </li></ul>
  • 10. Clinical Signs (1) <ul><li>Not breathing well </li></ul><ul><li>Not feeding well </li></ul><ul><li>Not looking well </li></ul>
  • 11. Clinical Signs (2) <ul><li>Respiratory </li></ul><ul><ul><li>dusky spells </li></ul></ul><ul><ul><li>tachypnea - sensitive but nonspecific - but respiratory distress in term newborn is sepsis until proven otherwise. </li></ul></ul><ul><ul><li>apnea in normal newborn - septic w/u and supportive measures should be knee-jerk reaction, then rule out other causes </li></ul></ul><ul><ul><li>increased A&amp;B episodes (growing premie) </li></ul></ul>
  • 12. Clinical Signs (3) <ul><li>Feeding </li></ul><ul><ul><li>not hungry </li></ul></ul><ul><ul><li>distension </li></ul></ul><ul><ul><li>residuals </li></ul></ul><ul><ul><li>vomiting </li></ul></ul><ul><ul><li>heme-positive stools </li></ul></ul><ul><ul><li>watery or mucousy stools </li></ul></ul>
  • 13. Clinical Signs (4) <ul><li>Appearance </li></ul><ul><ul><li>lethargic </li></ul></ul><ul><ul><li>mottled </li></ul></ul><ul><ul><li>poor perfusion </li></ul></ul><ul><ul><li>temperature instability (not necessarily fever, but fever is more specific) </li></ul></ul><ul><ul><li>early-onset jaundice </li></ul></ul>
  • 14. Clinical Signs (5) <ul><li>Chance Finding during Routine Tests </li></ul><ul><ul><li>Chemstrip </li></ul></ul><ul><ul><li>Urine dipstick - hemoglobin or sugar </li></ul></ul>
  • 15. Clinical Signs (6) <ul><li>Ominous Late Signs </li></ul><ul><ul><li>Apnea </li></ul></ul><ul><ul><li>Seizures </li></ul></ul><ul><ul><li>Hypotension/Shock </li></ul></ul>
  • 16. Clinical Signs (7) <ul><li>Sepsis-like Presentations: </li></ul><ul><ul><li>Ductal-dependent congenital heart disease </li></ul></ul><ul><ul><li>Inborn errors of metabolism (IEM) </li></ul></ul>
  • 17. Screening <ul><li>CBC with manual diff </li></ul><ul><ul><li>WBC: up, down, or normal </li></ul></ul><ul><ul><li>Left shift helpful but may be delayed </li></ul></ul><ul><ul><li>ANC, I/T ratio </li></ul></ul><ul><ul><li>Unexplained thrombocytopenia </li></ul></ul><ul><li>PT/PTT suddenly abnormal </li></ul><ul><li>Blood sugar may be high or low - change in pattern </li></ul><ul><li>ESR and CRP? Varies from center to center. </li></ul><ul><li>CIE or Latex fixation for GBS? Numerous false positives. </li></ul><ul><li>Gastric aspirate or ET aspirate? Not very specific. </li></ul>
  • 18. Workup (1) <ul><li>Workup During First 24 Hours of Life </li></ul><ul><ul><li>Blood culture </li></ul></ul><ul><ul><li>Amniotic fluid or placenta culture if available </li></ul></ul><ul><ul><li>ET aspirate (if intubated) </li></ul></ul><ul><ul><li>Very low yield for LP or urine cultures in first 24 hours unless specific clinical indication </li></ul></ul><ul><ul><li>LP later if blood culture positive or specific symptoms - but note that 10-15% of babies with positive LP have negative blood cultures </li></ul></ul>
  • 19. Workup (2) <ul><li>Classic Septic Workup (&gt; 24 hours, &lt; 30 days) </li></ul><ul><ul><li>Blood culture </li></ul></ul><ul><ul><li>LP </li></ul></ul><ul><ul><li>Urine - catherized or suprapubic aspirate </li></ul></ul><ul><ul><li>ET aspirate if intubated </li></ul></ul><ul><ul><li>Surface cultures skin/eye/secretions </li></ul></ul><ul><ul><li>Stool culture if stools abnormal </li></ul></ul><ul><ul><li>CXR </li></ul></ul><ul><ul><li>Abd. X-ray if symptomatic </li></ul></ul>
  • 20. Workup (3) <ul><li>Goals of workup </li></ul><ul><ul><li>Recover organism </li></ul></ul><ul><ul><li>Determine specific antibiotics </li></ul></ul><ul><ul><li>Determine antibiotic doses </li></ul></ul><ul><ul><li>Determine length of therapy </li></ul></ul>
  • 21. Treatment (1) <ul><li>Antibiotics </li></ul><ul><li>General supportive measures </li></ul><ul><li>IVIG? </li></ul><ul><li>GCSF or GMCSF? </li></ul>
  • 22. Treatment (2) <ul><li>General supportive measures </li></ul><ul><ul><li>Assisted ventilation and/or oxygen as needed </li></ul></ul><ul><ul><li>IV and possibly arterial access </li></ul></ul><ul><ul><li>NPO, NG suction if needed </li></ul></ul><ul><ul><li>Volume support, pressors </li></ul></ul><ul><ul><li>Transfuse if indicated </li></ul></ul><ul><ul><li>FFP/cryo if clotting disorders </li></ul></ul><ul><ul><li>Thermal regulation/support </li></ul></ul>
  • 23. Treatment (3) <ul><li>Selection of antibiotics based on: </li></ul><ul><ul><li>Age of onset </li></ul></ul><ul><ul><li>Location (home vs hospital) </li></ul></ul><ul><ul><li>Maternal history </li></ul></ul><ul><ul><li>Known colonization </li></ul></ul><ul><ul><li>Epidemic situations </li></ul></ul><ul><ul><li>etc. </li></ul></ul>
  • 24. Treatment (4) <ul><li>Late Onset (Home) </li></ul><ul><ul><li>GBS </li></ul></ul><ul><ul><li>GramNegatives </li></ul></ul><ul><ul><li>Herpes </li></ul></ul><ul><li>Early onset : </li></ul><ul><ul><li>GBS </li></ul></ul><ul><ul><li>E. Coli </li></ul></ul><ul><ul><li>Listeria </li></ul></ul><ul><ul><li>Others less common: </li></ul></ul><ul><ul><ul><li>Herpes </li></ul></ul></ul><ul><ul><ul><li>Staph aureus </li></ul></ul></ul><ul><ul><ul><li>Strep A and D </li></ul></ul></ul><ul><ul><ul><li>H. influenza </li></ul></ul></ul><ul><ul><ul><li>Klebsiella </li></ul></ul></ul><ul><ul><ul><li>Pseudomonas </li></ul></ul></ul><ul><ul><ul><li>Enterobacter </li></ul></ul></ul>
  • 25. Treatment(5) <ul><li>Late Onset (Hospital) </li></ul><ul><ul><li>Staph epidermidis </li></ul></ul><ul><ul><li>Gram negatives (often resistant) </li></ul></ul><ul><ul><ul><li>Pseudomonas, Klebsiella </li></ul></ul></ul><ul><ul><ul><li>Xanthomonas, Enterobacter </li></ul></ul></ul><ul><ul><ul><li>Serratia, Acinetobacter, etc. </li></ul></ul></ul><ul><ul><li>Candida (esp. if deep line) </li></ul></ul>
  • 26. Treatment (6) <ul><li>Antibiotic selection </li></ul><ul><ul><li>Early - usually Ampicillin and Gentamicin </li></ul></ul><ul><ul><li>Late onset for premie in hospital - Vancomycin and Gent or drugs specific to known colonization or epidemic situations. Third line drugs –Cefotaxime, Ceftazidime, Imepenam, Piperacillin, etc. </li></ul></ul><ul><ul><li>Abdominal catastrophes - Amp, Gent, Flagyl, etc. </li></ul></ul><ul><ul><li>Late onset home - Amp and Gent if&lt;30 days of age, Amp and Cefotaxime if greater than 30 days . </li></ul></ul><ul><ul><li>Fungus - Ampho, etc. </li></ul></ul>
  • 27. Aftermath(1) <ul><li>How long to treat? </li></ul><ul><ul><li>Was organism recovered? </li></ul></ul><ul><ul><li>Where was organism found? </li></ul></ul><ul><ul><li>Clinical course? </li></ul></ul><ul><ul><li>Repeat cultures? </li></ul></ul><ul><li>Sequelae? </li></ul><ul><ul><li>Few in uncomplicated neonatal sepsis </li></ul></ul><ul><ul><li>Frequent with NEC, gram-negative meningitis </li></ul></ul>
  • 28. Aftermath (2) <ul><li>Negative cultures and course not consistent with infection: 48-72 hours of treatment </li></ul><ul><li>UTI - 7-10 days treatment, screen for renal anomalies </li></ul><ul><li>Sepsis/NEC - 10-14 days of treatment </li></ul><ul><li>Meningitis: 14 days (GBS), 21 days (gram-negative), recommend ID consult </li></ul><ul><li>Osteo - prolonged treatment, get ID consult </li></ul>
  • 29. Prevention <ul><li>GBS - maternal prophylaxis &gt; 4 hrs PTD </li></ul><ul><li>Primary or active herpes - C/S </li></ul><ul><li>Chlamydia - maternal prophylaxis </li></ul>
  • 30. Future Trends <ul><li>GCSF or GMCSF </li></ul><ul><li>Monoclonal antibodies </li></ul><ul><li>Prophylaxis - various modes </li></ul>
  • 31. Specific Clinical Entities <ul><li>Gram negative </li></ul><ul><li>GBS </li></ul><ul><li>Herpes </li></ul><ul><li>Chlamydia </li></ul><ul><li>Mycoplasma/Ureaplasma </li></ul><ul><li>NEC </li></ul><ul><li>Listeriosis </li></ul><ul><li>Botulism </li></ul>
  • 32. Gram negative <ul><li>Gastrointestinal tract is a source of systemic neonatal infections caused by coliform and other Gram-negative bacteria </li></ul><ul><li>Septic shock is most commonly associated with Gram-negative bacterial sepsis </li></ul>
  • 33. Group B Streptococcus (GBS) <ul><li>Early onset - acquired from birth canal - typically pneumonia or mild septic picture but can be fulminant pneumonia with septic shock </li></ul><ul><li>Late onset - acquired from household contacts - more indolent presentation of fever + meningitis, sepsis </li></ul><ul><li>Changing clinical picture over 3 decades </li></ul>
  • 34. Necrotizing Enterocolitis (NEC) <ul><li>Distension, residuals (particularly bilious residuals), heme + stools </li></ul><ul><li>X-ray picture - pneumotosis intestinalis, portal air, free air, fixed loops, etc. </li></ul><ul><li>Supportive measures: antibiotics, volume + pressors, TPN, NPO, NG suction, etc. </li></ul><ul><li>Surgery indicated if free air, peritonitis, falling WBC or platelet count </li></ul><ul><li>First 24-48 hours is crisis period </li></ul><ul><li>Long-term damage is frequent - strictures, obstruction, malabsorbtion, dysmotility </li></ul><ul><li>Separate noon lecture for housestaff on this topic </li></ul>
  • 35. Herpes Simplex <ul><li>Birth to 1 month of age </li></ul><ul><li>Transmission: birth canal, postpartum contact, transplacental (rare) </li></ul><ul><li>Risk factors: primary infection &gt; 2ndary infection, PROM 18 hrs, instrumentation (e.g. scalp monitor), prematurity </li></ul><ul><li>Presentation: Local disease (skin eye mouth), disseminated disease (only 30% have skin lesions ), neurologic disease </li></ul><ul><li>Diagnosis: Culture </li></ul><ul><li>Treatment: Acyclovir </li></ul><ul><li>Prognosis: neurological disease 50% mortality, disseminated 80% mortality </li></ul>
  • 36. Chlamydia Trachomatis <ul><li>Transmission: birth canal. 20-30% lower SES are carriers, 50% of infants get infected </li></ul><ul><li>Risk factors: Colonized mom, PROM, prematurity </li></ul><ul><li>Presentation </li></ul><ul><ul><li>25-50% conjunctivitis - most common cause </li></ul></ul><ul><ul><li>5-20% pneumonia - gradual onset at 3-12 weeks, stacatto cough, tachypnea, rales, usually afebrile </li></ul></ul><ul><li>Diagnosis: IFA, ELISA, Giemsa stain, CXR interstitial </li></ul><ul><li>Treatment: Erythromycin </li></ul>
  • 37. Ureaplasma/Mycoplasma <ul><li>Transmission: birth canal, 40-80% carriers for ureaplasma, 21-50% mycoplasma </li></ul><ul><li>Presentation: non-acute pneumonia, ? meningitis, ? associated with stillbirths and chronic lung disease </li></ul><ul><li>Treatment: Erythromycin for symptomatic ureaplasma infections, no really good treatment for mycoplasma (tetracycline is contraindicated) </li></ul>
  • 38. Listeriosis <ul><li>Infections in newborns has a bimodal distribution,with early-oset septicemic infection associated with low birth weight,obstetric complications and maternal colonisations </li></ul><ul><li>Late onset disease tends to occur in infants with normal birth weight, with meningitis as a prominent finding, and is frequently associated with maternal colonisation or obstetric complications </li></ul>
  • 39. Infant Botulism <ul><li>Typical history is 3-6 week old infant with history of constipation and poor feeding progressing to apnea </li></ul><ul><li>Endemic in California, Utah, Pennsylvania </li></ul><ul><li>Raw honey has been implicated in some cases </li></ul><ul><li>Supportive therapy esp. ventilatory assistance, IV nutrition </li></ul><ul><li>No aminoglycosides! </li></ul>

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