Neonatal septicemia

Neonatal Septicemia Li Yijuan First Affiliated Hospital SUMS

Will They Have Good Future ???

Objectives What will I learn? Etiologies and risk factors Symptoms Diagnosis Treatment

Introduction
Common
-20% of VLBW has sepsis
-In term 0.1%
-Inter-institution difference 11-32%
(NICHD net work)
Serious
-mortality is 3-5 times more for infant
with sepsis in NICU

What is Neonatal Sepsis?
Neonatal Septicemia is a generalized
infection characterized by the proliferation
of organisms in the blood circulation during
the first month of life.

Some basic definitions
SIRS(systemic inflammatory response syndrome )
- fever, tachypnoea, tachycardia, abnormal WBC
Sepsis- systemic response to infection
Severe sepsis- sepsis with organ dysfunction, hypotension
Septic shock- severe sepsis with multiorgan dysfunction
difficult to apply these definitions and a staging system to the newborn

Pathogen
Staphylococcus
Escherichia coli
Conditional pathogen
Group B streptococcus

Staphylococcus

E. Coli

Staphylococcus epidermidis

Pseudomonas aeruginosa

Klebsiella

Clostridium perfringens

Group B -hemolytic streptococcus

Route of Infection
Prenatal infection
infection during delivery
postnatal infection

Sepsis Risk Factors
Prematurity
Birth weight
Term 0.1%
1,000 -1,500 g 10%
<1,000 g 35%
<750 g. 50%
Delay enteral feeding and Prolonged TPN

Risk Factors (maternal and neonatal)
Major
Maternal prolonged Rupture of Membranes >24 hours
Intrapartum maternal fever >38 C (>100.4 F)
Chorioamnionitis
Sustained Fetal Tachycardia >160 beats per minute
Minor
Intrapartum maternal fever >37.5 C (>99.5 F)
Twin Gestation
Premature infant (<37 weeks)
Maternal Leukocytosis ( White Blood Cell count >15000)
Rupture of Membranes > 12 hours
Tachypnea (<1 hour)
Maternal Group B Streptococcus Colonization
Low APGAR (<5 at 1 minute)
Low birth weight (<1500 grams)
Foul lochia

What makes a neonate’s immune system susceptible to sepsis? Maturity Immaturity or

You’re Right!!!! The immaturity of a neonate’s immune system makes them MORE SUSCEPTIBLE to sepsis.

Why are newborns so vulnerable to infection? Non-specific immunity Specific immunity

Why are newborns so vulnerable to infection? IMMUNE SYSTEM Neutrophils – Qualitative and quantitative Complement and immunoglobulin levels decreased T cells- antigenically naïve limited cytokine production

Poor skin barrier

Umbilical stump

Poor blood-brain barrier

Classification
Early onset sepsis (EOS):
bacteria acquired before and during delivery
5-7/1000 live birth
1.5% of VLBW infants had EOS (intrapartum antibiotics)
Late onset sepsis (LOS):
bacteria acquired after delivery (Nosocomial or community)
20% of VLBW infants

Clinical menifestations EOS LOS Onset Within 7 days >7 days Source Prenatal During delivery During delivery Postnatal(nosocomial ) Pathogens G - bacili S taphylococcus ; Opportunitic P resentation Mortality P neumonia High Bacteremia and / or meningitis Low

Symptoms of Neonatal Sepsis The symptoms are not concrete and vary widely Tachypnea Heart Rate Changes Feeding difficulties Difficulty Breathing Temperature Instability J aundice Irritability

Omphalitis

Bleeding tendency Poor perfusion

Enlargement of liver and spleen

toxical paralytic ileus

dyspnea

Clinical presentation Early warning signs are often non-specific and subtle  easily confused with non-infective causes (e.g. apnea of prematurity, variation in environmental temperature or acute exacerbation of chronic lung disease)  clinical course alarmingly fulminant  septic shock + DIC  death Non-specific, multi- systems/organs involved

Clinical manifestation The symptoms are so broad , non-specific , and acute deterioration , How to make a diagnosis as early as possible ?

Laboratory studies
Evidence for inflammation
Evidence for infection
Evidence for multiorgan system disease

Laboratory Examination: CBC
WBC<5×10 9 /L or WBC>20× 10 9 /L
I/T≥0.2 ， toxic granules
thrombocytopenia <100×10 9 /L

Reference values for neutrophilic cells Manroe BL, J Pediatr 1979;95:89-98.

Total neutrophils Immature neutrophil I/T ratio

Lab examination:CRP
CRP
α1-AG
α1-AT

Lab Exam: Organism detection  blood culture  culture of body fluid and secretion  plasma brown layer smear --Detection of antigen: usually for antibody of GBS or E coli in CSF, blood and urine --Molecular biochemical method PCR

Summary Is there a diagnostic marker for neonatal sepsis?

Great answer! You’re correct!
There is NOT a specific diagnostic marker, only determinants of infection

Summary
The best approach for diagnosis of systemic bacterial infection:
use of multiple markers (e.g. CRP, IL-6, TNF  , CD64), and
serial measurements

Diagnosis
history
– high risk factors
clinical manifestation
--nonspecific S/S
lab results
- abnormal blood routine,
CRP, positive culture
or detection of organisms

Therapy
Infection should be the first thought when an infant has symptoms
Aggressive treatment should begin before the diagnosis is confirmed.
Therapy can be discontinued if sepsis is excluded

Treatment  Antibiotics therapy  management of complications  supporting therapy  Clearance of infectious focus  Immunotherapy

Antibiotic therapy
using antibiotics as early as possible
choose antibiotics according to drug sensitivity
giving drugs intravenously
combine effective drugs to make synergism
enough therapeutic course
consider the possible side effects

Dosages of antibiotics for newborns

Supporting therapy
Nursing care
--warm environment
--oxygen supply
correction of acidosis and electrolyte disturbance
fluid , glucose and nutrition balance

Management of complications
Shock
DIC
Cerebral edema
Pulmonary hemorrhage

Immunotherapy
IVIG
Exchange transfusion
Granulocyte transfusion ， G-CSF
Platelet transfusion

Questions
Could prophylatic IVIG reduce the morbidity and mortality of neonatal sepsis?
Might prophylatic IVIG interfere the development of the neonatal IM system?

Thank you for your attention

Neonatal septicemia

by Sumit Prajapati

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