Neonatal sepsis management


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  • Hi saptharshi.... very gd evening... im dr.dasaratha, I/C NICU at an NGO hospital. it is 30 bedded with level 3 care.... its a charity hospital for all socially backward classes.... i have read ur ppt on neonatal sepsis... thank u somuch for the information... can u please send me the powerpoint presentation to my mail....
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Neonatal sepsis management

  1. 1. Objectives• Antibiotic essentials – Which one? Rationale? – Duration of treatment – Practical applications• Supportive Care – Neonatal septic shock• Adjunctive therapies• Follow up care
  2. 2. All about antibiotics - BasicsPARENTERAL ANTIBIOTICS
  3. 3. CASE SCENARIOsCASE 1: B/o S CASE 2: B/o M• 38 wk/ 2.8 Kg/ AFD/ Mch • 34 wk/ 1.2 Kg/ SFD/ Fch• Day 8 of life • Day 1 of life• Born in PGI via NVD • Born via NVD at home• Discharged on D 2 • Brought with• Brought with 2d history of – Poor feeding – Episodes of vomiting – Lethargy – Lethargy – Tachypnea – Abnormal movements • Examination shows sclerema• Sepsis screen – POSITIVE • Which antibiotic will you start?• CSF s/o meningitis• Which antibiotic will you start?
  4. 4. Empirical Antibiotic therapy Choice of antibioticsBased on the organisms responsible for the infection in that region (local data) Based on the sensitivity patterns of the organisms in that region (local data) REVIEW DATA 6 MONTHLY
  5. 5. EONS Vs. LONS• EONS /LONS in the developed world – Rationale for the concept• Indian data on EONS and LONS – NNPD 2002-03  Different findings EONS / LONS division – ARTIFICAL No difference between EONS and LONS in our settings
  6. 6. Organisms causing EOS/LOS Author / year Isolates Outcome Comments1. Zaidi et al 3209 isolates – Klebsiella – 25% WHO (Young PIDJ 2009 1st week of life E.Coli – 15% Infant study) S. aureus – 18% included Developing GBS – 7% countries – 63 studies (1980 – 2007) 835 isolates – S.Aureus – 14% Home deliveries – 7 to 28 days GBS – 12% 77% Gram -ve Pneumococci- 12% organisms Klebsiella – 4%2. NNPD 2002- 18 Tertiary K.pneumonia-32.5% Intramural births 03 care neonatal S.aureus – 13.6% Indian data units K.Pneumonia – 27% Extramural births S.Aureus – 15%
  7. 7. Original Article Blood Culture Confirmed Bacterial Sepsis in Neonates in a North Indian Tertiary Care Center: Changes over the Last Decade Venkataseshan Sundaram, Praveen Kumar*, Sourabh Dutta, Kanya Mukhopadhyay, Pallab Ray1, Vikas Gautam1, and Anil Narang Department of Pediatrics and 1Department of Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India (Received March 21, 2008. Accepted December 3, 2008 ) SUMMARY: The spectrum of organisms causing sepsis is different in developing countries. Data on the recent trends of organisms causing sepsis are limited. This study was conducted in a tertiary care neonatal unit in Northern India. All inborn babies with blood-culture-positive sepsis from 1995 to 2006 were divided into two epochs, viz. 1995 to 1998 (epoch I) and 2001 to 2006 (epoch II). Organisms were grouped into early (<72 h) and late onset (≥72 h) sepsis groups. The overall incidence of sepsis, the incidence of sepsis stratified by weight groups, the organism profile on different days of life, sepsis-related mortality and pathogen-specific case fatal- ity rate were calculated and compared between the two epochs. Out of 34,362 live births during the study period, organisms were isolated in 1,491 neonates. Out of these, 89% had bacterial sepsis. The incidence of neonatal bacterial sepsis increased from epoch I to epoch II (35.8/1,000 versus 40.1/1,000 live births, P < 0.05). The incidence of early onset sepsis (EOS) did not change between the epochs, but the incidence of late onset sepsis (LOS) increased from 12 to 16.5 per 1,000 live births (P < 0.001). The incidence of bacterial sepsis decreased significantly in the 1,000- to 1,999-g birth weight groups. Klebsiella pneumoniae and Enterobacter aerogenes decreased, whereas Staphylococcus aureus increased in incidence during epoch II. Non-fermenting Gram-negative bacilli emerged as a newly identified pathogen during epoch II. Sepsis-associated mortality decreased from 42 to 20%. The incidence of bacterial sepsis has decreased significantly in 1,000- to 1,999-g infants, with a significant reduction in sepsis-related mortality. New organisms have emerged in recent years. The organism profile in recent years has changed, with a significant overlap of organisms causing EOS and LOS. of major changes in neonatal care, the study period was INTRODUCTION divided into two epochs, viz. 1995 to 1998 (epoch I) and 2001 Neonatal infections are estimated to cause 1.6 million to 2006 (epoch II). Since the changes in peri/neonatal caredeaths every year globally, and 40% of all neonatal deaths were gradual, the intervening period of 1999 - 2000 was
  8. 8. Empirical Antibiotics - PGI• Based on PGIMER NICU data – Ciprofloxacin / Amikacin : 75% isolates – Vancomycin/Pip-tazo: 90% isolates – Vancomycin/Meropenem: 95-100% AVOID Cefotaxime as empirical first line antibiotic Production of ESBLs Fungal colonization
  9. 9. Back to the case scenarios…CASE 1 B/o S CASE 2 B/o M• Cefotaxime 200 mg/kg/d • Ciprofloxacin 10 IV in 3 divided doses mg/kg/dose Q12 hourly slow push IV infusion over 30-60 min• Amikacin 15 mg/kg/day • Amikacin 7.5 mg/kg/day IV Q 24hourly infuse over 1 hour IV Q 24 hourly infuse over 1 hour
  10. 10. Antibiotics• Timeliness of initiation – First dose – Important prognostic factor – Delay in antibiotics – worsening outcomes• Route of administration – Only Intravenous – No role for any other route – Oral therapy – not recommended
  11. 11. Dose of Antibiotics• Always check before every dose- everyday- everytime• Dependent on postnatal age / weight / gestational age• Standard source of information – “The Blue Book” – PGI NICU Handbook of Protocols – 4th Edition – 2010 – NEOFAX & LEXI COMP – Pediatric & Neonatal drug dosage handbook
  12. 12. Newer drug dose info sourcesEPOCRATES – Free android & I pad appOther applications/ software Web MD Drug Handbook
  13. 13. CSF penetration of commonly used antibioticsANTIBIOTIC CSF penetrationCiprofloxacin GoodCefotaxime Very goodAmikacin Good* (inflamed meninges)Gentamicin Good* (inflamed meninges)Vancomycin Good* (inflamed meninges / continuous infusion of 60 mg/kg/day)Pip –Tazobactam Poor (Poor penetration into CSF)Imipenem Good (Propensity for seizures)Meropenem Good* (higher doses/ infusion)Amphotericin B Poor (both conventional & Liposomal)Fluconazole Good
  14. 14. Practical points
  15. 15. Practical points
  16. 16. Empirical modification of empirical antibiotic therapy• Empirical upgradation of antibiotics if no clinical improvement within 48-72 hours• Extremely sick neonate  Even earlier – after discussing with consultant/ seniors
  17. 17. After POSITIVE blood c/s…• report… S  Narrower spectrum ABx / lower cost – DOWNGRADE even if neonate was improving• Use a single sensitive antibiotic – (Exception: Pseudomonas, S.aureus, E. fecalis, Acinetobacter spp.)• S  Empirical antibiotics but clinical worsening – Possibility of ‘in vitro’ resistance – Change antibiotics• R  Empirical antibiotics but clinical improvement – Do not change antibiotics (exceptions*) – Possibility of ‘in vivo’ sensitivity
  18. 18. Duration of antibiotic therapy Meningitis (c/s proven) : 21 days Urinary tract infections : 7-14 days Proven bone/joint infections : 6 weeks
  19. 19. After NEGATIVE blood c/s…• Asymptomatic neonate: Stop ABx• Suspected EOS/LOS, neonate improves but not fully asymptomatic: – Repeat CRP assay & re-evaluate clinical data – CRP > 10  antibiotics for 7 days – CRP: negative & clinical data negative  Stop• Suspected EOS/LOS, neonate has worsened clinically: – Evaluate for causes other than sepsis – Empirically upgrade antibiotics if sepsis suspected
  20. 20. Case 3 B/o K• 34 wk/ 1.7 kg/ AFD/ F ch• Seen by you at a primary health centre at least 300 km away from a tertiary hospital• Brought with rapid breathing/ poor feeding• You are unable to establish IV access• What will you do? Stabilize ABC and Temperature Administer first dose of IM Amikacin Transport with appropriate supportWhich other antibiotic can be given IM safely in neonates?
  21. 21. Now, tell me this… Highly protein bound Displaces bilirubin Risk of KernicterusRef: Pediatrics 2012; 129: 1006
  22. 22. Management of Organ dysfunctionSUPPORTIVE CARE
  23. 23. Supportive Care•Equally important componentof care•Early recognition of organdysfunction•Development of MODS –significant rise in mortality•Watch for SEPTIC SHOCK inparticular
  24. 24. What all should you monitor?CLINICAL•Temperature  MOST IMPORTANT – Nurse in thermo-neutral environment – Avoid hypo as well as hyperthermia•Aggressive nutritional support – Early enteral feeding•Rigorous monitoring especially hemodynamic parameters – Closely watch core-periphery temperature difference – Capillary refill time/ urine output & others – Non-invasive BP monitoring
  25. 25. What all should you monitor?LABORATORY•Monitor pH/ BE/ lactate (ABG/VBG)•ECG/ CXR/ Echo (if necessary)•Sugar / Na/ K/ other metabolic parameters•Conjugated jaundice (sepsis induced)•Hemoglobin/ platelets / counts•Coagulation profile / liver function tests
  26. 26. Supportive Care• Mechanical ventilation• Exogenous surfactant therapy• Timely volume & vasopressor support• Anti- convulsants for seizures• Echocardiography for PDA• Ultrasonography Head *
  27. 27. Neonatal Septic Shock• Early recognition – determines survival• Distributive + Cardiogenic – Volume to EARLY recognition of shock 20 min CLUES support: 10 – 20 ml/kg NS over – •Tachycardia / bradycardia factors: Ca/ Correct negative ionotropic in preterms pH/ Sugar – •Cool/ pale skin/ mics/kg/min Dopamine 5 – 20mottling •Delayed capillary refill / cold peripheries – Dobutamine 5 – 15 mics/kg/min •Weak peripheral pulses – Adrenaline 0.05 – 0.3 mics/kg/min (inotrope) •Narrow pulse pressure (Raised DBP) •Oliguria / Ileus – 1 mics/kg/min vasoconstriction) 0.3 (s/o splanchnic (vasopressor) •Wide pulse 1-3 mg/kg HYDROCORT pressure Q 8 hourly •Lethargy / decreased urine (poor response to dopamine) output •Metabolic acidosis
  28. 28. Case 3: B/o M• 38 wk/ 3.1 Kg/ AFD/ Mch – D 17 of life• Brought to PGI Emg. in a state of shock• History of poor feeding/ lethargy along with episodes of hypothermia over last 4 days• You start the baby on Cefotaxime & Amikacin as per our protocol• What else would you like to do?
  29. 29. Answer• Would you not like to do a lumbar puncture? – YES• But, if the baby is on multiple ionotropes? – YES ? NO ?• In an unstable neonate, the LP can be deferred until stabilization Cellular & Biochemical abnormalities persist for 72 hours Gram positive bacteria clearance occurs in 36 hours Gram negative bacteria clear in 120 hours
  30. 30. Upcoming modalitiesAdjunctive therapies
  31. 31. Intravenous Immunoglobulin
  32. 32. Intravenous Immunoglobulin
  33. 33. International Neonatal Immunotherapy Study NEJM 2011;365:1201­11 • Multicentric randomized clinical trial • 3493 neonates • Two doses at 500 mg/ kg or matching placebo 48 hours apart • No difference in sepsis /mortality • No difference in long term (2yr) outcome
  34. 34. Granulocyte transfusion• Use justified by reduced number and abnormal function• Produced by leukopheresis✗ The Cochrane Library 2011, Issue 10
  35. 35. GCSF & GM­CSF• Glycoprotein• Deficient in premies; Resistance also described• Dose 5­10mcg/kg/day for 3 days✗ Cochrane Database of Systematic Reviews 2009, Issue 3
  36. 36. Exchange transfusion• Removal of bacteria, endotoxins & inflammatory mediators• Improved opsonic & granulocyte activity• Improved O2 carrying capacity✔ ✗ Clinics in perinatology,2010
  37. 37. Pentoxifylline• PD inhibitor and reduces TNFα• Improves endothelial function and avoids excessive coagulation✗ The Cochrane Library 2011, Issue 10
  38. 38. Selenium & Melatonin• Free radical scavengers✗ Clinics in perinatology 2010
  39. 39. Glutamine• Anabolic for dividing immune and gut cells✗ Clin Perinatol 37 (2010) 481–499
  40. 40. FOLLOW­UP CARE• Growth monitoring• Hearing screen – who received Aminoglycosides• Monitoring organ dysfunction• Meningitis babies on OPD F/U: – Weekly OFC – Neurological examination – Hearing screen (discharge + 3 months) – USG Head (1st week/ End of Rx/ Follow­up) – Anti­epileptics (stop before discharge/ 3 months)• If proven UTI, start AMOXICILLIN 10 mg/kg OD oral prophylaxis & plan USG KUB, MCU & DMSA
  41. 41. TAKE HOME MESSAGE• Empirical antibiotics – Start early, choice, in correct dose, correct mode of administration, check CSF penetration & side effects• Collect blood c/s, correlate with clinical picture & modify therapy as early as possible• Supportive care & monitoring (clinical & lab) – keeps the baby alive & buys time for antibiotics to act• No proven role for any adjunctive therapies at present• Follow­up care with focus specific monitoring – also determines long term outcome
  42. 42. Hope we can saveneonates before they reachthis state of NO RETURN