7We CareNeonatal SepsisClinical syndrome of bacteremia with systemicsigns and symptoms of infection in the firstfour weeks of life.
7We Care• Incidence:India: 9-60/1000 live births(average:38/1000)• Almost 5 times higher than in developedcountries• Causes 20% of neonatal deaths• Incidence is 5-10 times higher in LBW andpreterms than normal weight term babies
7We Care• Immunological response to infection• Release of a cascade of cytokines– both pro and anti inflammatory– secondary to bacterial endotoxins or exotoxins• Cytokines SIRSseptic shock +MSOFSepsis is a very rapidly progressive conditionwhich can kill even before diagnosis
7We CareETIOLOGY• E coli• Klebsiella• CONS• Staphylococcus aureus• GBS• Pseudomonas• Acinetobacter• Citrobacter• Candida albicans and non albicans candida
7We Care1. Feeding ability reduced2. No spontaneousmovement3. Temperature >380C4. Prolonged capillary refilltime5. Lower chest wallindrawing6. Resp. rate > 60/minute7. Grunting8. Cyanosis9. H/o of convulsionsClinicalClinical featuresfeatures of severeof severeinfectionsinfections
7We CareDiagnosis of neonatal sepsisDirect- Isolation of organisms from blood, CSF, urineis diagnosticIndirect-Screening tests
7We CareSepsis screenLeukopenia (TLC < 5000mm3)Neutropenia (ANC < 1800/mm3)Immature neutrophil to total neutrophil(I/T) ratio (> 0.2)Micro-ESR (> 15mm 1sthour)CRP +ve*If two or more tests are positive treat infant as neonatal sepsis
7We CareMature neutrophil Band cellNeutrophils
7We CareMeningitis10-15 percent cases of sepsis have meningitisMeningitis can be often missed clinicallyLP must be done in all cases of late onset &symptomatic early onset sepsis
7We CareManagement• Mainstays of therapy:– Early recognition– ABC’s - supportive care– Appropriate and adequate antimicrobials
7We CareManagement: Supportive careKeep the neonate warmIf sick, avoid enteral feedStart IV fluids,infuse 10% dextrose to maintain normoglycemiaMaintain fluid and electrolyte balance and tissueperfusionIf CRT >3 sec, infuse 10 ml/kg normal saline bolus.
7We CareSupportive care• cyanosed / RR >60/min / severe chestretractions– Start oxygen by hood• sclerema– Consider exchange blood transfusion/IVIG.
7We CareSuspected neonatal sepsisStart parenteral antibioticsSend cultures (report in 72 hrs)Culture -ve Culture +veClinically nosepsis (Stop Ab)Clinically ill(Cont Abx7-10D)Pneumonia, Sepsis(Cont Ab X 7-10D)Meningitis, Osteomyelitis(Cont Ab X 3-6 wks)
7We CareChoice of antibiotics• Pneumonia or SepsisPenicillin Aminoglycoside(Ampicillin or Cloxacillin) (Gentamicin or Amikacin)• MeningitisAmpicillin + GentamicinOrGentamicin or Amikacin + Cefotaxime or Ceftriaxone+
7We Care• Change to Third gen CP in case of gm-veenteric bacilli like E.coli.• L.monocytogen: resistant to cp treat withampicillin and gentamycin.• Add Vancomycin if MRSA and enterococci.• VRE add linezolid/quinipristin.• Pseudomonas: combination of two agents likeceftazidime,piperacillin/tazobactem,genta/amikacin.Which Antibiotics
7We Care• ESBLs: many strains of E.coli,klebsiella,pseudomonas serratia etc foundwith these resistant enzymes.Carbapenems,cefepime andpipera/tazobactem are most effective.
7We CareOther measures in LOS• IVIG• G-CSF• PROBIOTICS• LACTOFERRIN• EARLY ENTERAL FEEDING.
7We CareSuperficial infectionsPustules - After puncturing, cleanwith betadine and applylocal antimicrobialConjunctivitis - Ciprofloxacin eyedropsOral thrush - Local application ofnystatin or Clotrimazole
7We CareCleans• Surfaces : housekeeping• Hands– 2 minutes wash : first time– Use of disinfectant between any outer object and baby– Rolled up sleeves– Nails– Rings , watches– Nail polish
7We CareA scanned picture of steps of handwashingSix steps of hand washingStep 1Wash palms with fingersStep 2Wash back of handsStep 3Wash fingers & knucklesStep 5Wash finger tipsStep 6Wash wristsStep 4Wash thumbs
7We CareHand washingSimplest, most effective measure for preventinghospital acquired infections2 minutes hand washing prior to entering nursery15 seconds of hand washing before touching babyAlcohol based hand rub effective but costly
7We CareThe birth of a baby• Are we able to maintain asepsis in the deliveryroom?– Mother– Birth attendant for the mother– Birth attendant for the baby– Objects in the resuscitation of the baby– Hygiene of practices at the time of birth
7We CarePrevention of Infections• Exclusive breast feeding• Keep cord dry• Hand washing by care givers• Hygiene of baby• No unnecessary interventions
7We CareIntravenous lines:Peripheral• Skin preparation• Maintenance after insertion• Extravasation/thrombophlebitis• Flushing solutions• Change IV infusion sets daily• Replace IV tubings used to give blood / bloodproducts at end of infusion• Barrier precautions during line change
7We CareDisposal of waste and soiled linen• Safe disposal• Colour coding• Sharps• Infected wastes
7We CareWork cultureSterile gowns and linen for babiesHand washing by allRegular cleaning of unitNo sharing of baby belongingsDispose waste-products in separate bins
7We CareControl of hospitalinfectionsHand washing by all staffIsolation of infectious patientUse plenty of disposable itemsAvoid overcrowdingAseptic work cultureInfection surveillance
7We CareControl of hospital outbreak ofinfectionsEpidemiological investigationIncreased emphasis on hand washingReinforce all preventive measuresReview of protocols of nurseryScreen all personnelReview of antibiotic policyCohorting of infants
7We CareFumigationUse Potassium permanganate 70 gmwith 170 ml of 40% formalin for 1000cubic feet area for 8-24 hoursalternativelyBacillocid spray for 1-2 hours may be equallyeffective
7We CareConclusions• High index of clinical suspicion• Look for lab evidence of sepsis• Start parenteral antibiotics (I.V.)• Provide supportive care• Review culture report• Practise barrier nursing to prevent cross-infection
7We Care• Neonatal sepsis is a serious disease• Suspect early and admit to NICU/Ward• Start AB in preterms for suspected sepsis(maternal risk factors )even if asymptomatic• Treat all cases of probable or proven sepsiswith antibiotics• Give supportive and adjunctive treatment• Prognosticate cautiously