Neonatal Sepsis and Necrotizing Enterocolitis

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  • 1. Neonatal Sepsis, Necrotizing Enterocolitis Dr. Kalpana Malla MD Pediatrics Manipal Teaching HospitalDownload more documents and slide shows on The Medical Post [ www.themedicalpost.net ]
  • 2. Neonatal SepsisClinical syndrome of bacteraemia characterized by systemic signs and symptoms of infection in the first four weeks of lifeBacterial invasion and multiplication in theblood07/01/2012 2
  • 3. IncidenceIn India - 3.9 % of all imtramural births - 20 – 30 % develop meningitisIn developed countries - 1 in 1000 live births - Term - 4 in 1000 live births - Preterm - 300 in 1000 VLBW babies 07/01/2012 3
  • 4. EtiologyCommon - E.coli, Klebsiella, Pseudomonas, Proteu s,Others- Staph. aureus, streptococcus ssp, acintobactor, H. inlfluenzae, Anaerobes, L monocytogens, GBS, Enterococcus,Citr obacter 07/01/2012 4
  • 5. Maternal Risk Factors1. Intrapartum - Maternal Infection - Purulent / foul smelling liquor - Fever (>380C) - Leucytosis (WBC >18000 / mm3)2. Premature rupture of membranes3. Prolonged rupture of membranes > 12 hours4. Premature onset of labour (<37 weeks5. Maternal UTI6.Meconium stained liquor7.Chorioamnionitis 07/01/2012 5
  • 6. Neonatal Risk factors 1. Low Birth Weight Baby/Preterm 2. Perinatal asphyxia 3. Male gender 07/01/2012 6
  • 7. CLASSIFICATION1. Early onset –• < 72hrs of age - Before or during deliveryⓐ PROM →Ascending Chorioamninitisⓑ During passage through birth canalⓒ Resuscitation at birth – added risk in the OT & LR• Organisms from - maternal genital tract, LR,OTOrganisms :• E coli., Klebsiella, GBS,
  • 8. CLASSIFICATION2. Late-onset• >72hrs-30 days of age mostly end of 1st week.ⓐ Nosocomial infection/Hospital inf. Source: Organisms from NICU, postnatal ward. Incubators, Resuscitators, Ventilators, Cathe ters, Infusion sets, Face masks.Organisms• Staph aureus . epidermidis, E.coli, Klebsiella, pseudomonas, prot eus (2/3 are by gram –ve bacilli), Enterobacteriae
  • 9. CLASSIFICATIONⓑ Community infection • After discharge from hospital Source - mother, family, contacts, baby care units,Organisms: • Strepto pneumoniae • Tuberculosis • Viruses
  • 10. CLASSIFICATION3. Late-late onset• After 30 days of ageOrganisms- saph. epidermidis, E.coli, candida, Tuberculosis Viruses
  • 11. Early vs Late onset sepsis Early onset Late onsetAge <72 hours >72 hoursRisk factor Prematurity Prematurity Amnionitis, Maternal infectionSource Maternal genital Environmental tract (nosocomial)Presentation Fulminant slowly progressive Multisystem focal Pneumonia frequent Meningitis frequentMortality 5-50% 10-15% 07/01/2012 11
  • 12. Symptoms of Neonatal Sepsis1. CNS Lethargy, Refusal to suck, Limp, Meningitis seen in 1/3 of all cases- bulging fontanelle. High pitched cry, excessive crying, convulsions, Not arousable, Irritable, Hypothermia in preterm, fever in older babies2. CVS Shock-pallor, Cyanosis, Cold and clammy skin cap filling>2 sec3.Respiratory Tachypnoea, Apnoea, Grunt, Retractions 07/01/2012 13
  • 13. Symptoms of Neonatal Sepsis4.GIT Vomiting, Diarrhoea, Abdominal distension, NEC,blood in stool5.HaematologicalBleeding manifestations-DIC, pulmonary Hge, IVH , NNJ6.Skin Rashes, Purpura, Pustules, Sclerema (skin thick, unpinchable, involves face ,chest, legs) 07/01/2012 14
  • 14. SEPSIS SCREENAt BirthMajor risk factors 1. Rupture of membranes > 24 hrs 2. Maternal intrapartum fever > 100.40 F (>38oC) 3. Chorioamninitis 4. Sustained fetal heart rate >160/minMinor risk factors 1. Rupture of membrane > 12 hours 2. Maternal intrapartum fever > 99.50 F , ≥37.5oC 3. Maternal WBC > 15000 / mm3 4. Low apgar score(< 5 at 1 min, < 7 at 5min) 5. LBW ( < 1500 g ) 6. Preterm labour ( < 37 weeks) 07/01/2012 15
  • 15. Minor risk factorsMinor risk factors 7.Foul smelling liquor/ meconium stained 8.Maternal WBC Count >15,000 9.Maternal GBS colonization 10.Low APGAR score(<5 at 1min) 11.Multiple gestation 12. > 3 vaginal exam**1 major or 2 minor risk factors
  • 16. Laboratory Diagnosis of NNS1. Direct methods - Blood culture - CSF culture - Urine culture2. Indirect methods / Screening tests - TLC < 5000 / mm3) - ANC <1800 / mm3) - Total immature neutrophils (Band neutrophil count >20%- Immature neutrophil (Band N) to total neutrophil ratio ( > 0.2) - Micro ESR( > 15 mm / 1st hour ) 07/01/2012 17
  • 17. 2. Indirect methods / Screening tests - Acute phase reactants- CRP - positive - Buffy coat examination - Smear of gastric aspirate- >5 neutrophil /HPF - C3d - Toxic granules, cytoplasmic vaculation, dhole bodies in PS
  • 18. Lab diagnostic criteria• Septic screen- if 3 are abnormal chance of infection 90%A) TLC>20,000 or <5000B) Bands >20% or band: neutro>0.2C) abnormal neutrophils-toxic granulesD) micro ESR>15mm/1st hrE) CRP >8mcg/mlOthers-elevated haptoglobin,alpha-1antitrypsin fibrinogen
  • 19. Management of Neonatal Septicemia1. Antibiotic Therapy2. Supportive Therapy3. Immunotherapy
  • 20. Antibiotic Therapy• Antibiotic started on clinical grounds tillC/S reports: Initial choice**EOS – Aminoglycoside + Ampicillin or Crystallin Pencillin + Gentamycin / Amikacin **LOS – Aminoglycoside + Cloxacillin• Pseudomonas: Ceftazidime• Staph. Aureus: Vancomycin++Meningitis – aminoglycoside +Cefotaxime• Duration: Septicemia- 10 to 14 days• Pneumonia- 14 days• Meningits- 21 days
  • 21. Supportive care:• IV fluids, glucose,• Vit K, anticonvulsants• Blood transfusion,• Shock-Dopamine, Dobutamine,Steroids• Phototherapy, Oxygen• Hypoglycemia: 10% dextrose• FFP• Ventilatory support
  • 22. Immunotherapy• IVIG• Exchange blood transfusion - if there is sclerema, DIC, Neutropenia• Granulocyte transfusion - Colony Stimulating Factors• Prognosis-upto 50% mortality
  • 23. Natural course of sepsis Bacteria Focal infection Bacteraemia sepsis Sepsis syndrome Early septic shock Refractory septic shock MODS Multiple organ dysfunction syndrome07/01/2012 24 DEATH
  • 24. Evaluation of symptomatic infant for sepsis - Sepsis screen - Chest X-ray - Lumbar puncture - Blood culture Begin AntibioticsCulture positive No risk factors for sepsisPresence of focal infection Culture negativeSepsis screen positive Sepsis screen negativeLP abnormal Symptoms resolve by 24 hrsSymptoms persists 72 hrsTreat pneumonia 7-10 days Treat for 48-72 hrsSepticaemia 10-14 days and dischargeMeningitis 14-21 days
  • 25. Superficial Infections - Pustules - After puncturing, clean with betadine and apply antimicrobial - Conjunctivitis- Chloramphenicol eye drops - Oral thrush - Local application of Nystatin or Clotrimazole07/01/2012 26
  • 26. Prevention of Infection - Exclusive breastfeeding - Keep cord dry - Hand washing by care givers - No unnecessary intervention - Better management of IV Lines - Disinfection of Equipments07/01/2012 27
  • 27. Hand Washing - Single most important means of preventing nosocomial infections - Very Simple - Cheap07/01/2012 28
  • 28. 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 fomites07/01/2012 29
  • 29. 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 elbow07/01/2012 30
  • 30. 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 WASHING07/01/2012 31
  • 31. NECROTIZING ENTEROCOLITIS Definition • An idiopathic coagulation necrosis and inflammation of the intestine in a neonate.07/01/2012 32
  • 32. Incidence• 0.5 - 3.5/1000 live births• Affects mostly premature infants (10% occur in FT)• Increased incidence with decreasing BW and GA• Hypothesis - the risk of NEC is determined by maturity of the GI tract07/01/2012 33
  • 33. Age of Onset• The age of onset is highly variable but rarely occurs in the first three days of life• The lowest GA (24-28 weeks) tend to develop NEC after the second week of life• Intermediate GA (29-32 weeks) develop it within 1-3 weeks• Term infants or >32 weeks tend to develop it in the first week of life07/01/2012 34
  • 34. Risk Factors• low APGARS,• UAC• severe RDS,• PDA’s (ie gut ischemia),• Aggressive and early enteral feeding in a premature infant• Prematurity (with immature GI tract and host defenses) is the primary risk factor 07/01/2012 35
  • 35. Clinical Manifestations • Bell’s staging criteria Stage I (suspected NEC) Stage II (definite NEC) Stage III (advanced NEC, severely ill) IIIA (without perforation) IIIB (with perforation)07/01/2012 36
  • 36. Clinical manifestations • Stage I • Systemic signs • Temp instability • Intestinal Signs • Mild abdominal distention, emesis • Radiological signs • Normal or mild dilatation or ileus07/01/2012 37
  • 37. Clinical Manifestations Stage II • Systemic signs • Same as Stage I with metabolic acidosis and mild thrombocytopenia • Same as Stage I with decreased bowel sounds • Intestinal signs and abdominal tenderness • Intestinal dilatation, ileus and pneumatosis • Radiologic signs intestinalis07/01/2012 38
  • 38. Clinical Manifestations Stage III (A & B) • Systemic signs • Same as II plus hypotension, severe apnea, DIC, neutropenia, anuria • Intestinal signs • Same as II with generalized peritonitis, marked tenderness and distention, and abdominal wall erythema • Radiologic signs • Same as II with portal vein gas, definite ascites pneumoperitoneum07/01/2012 39
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  • 42. Radiologic findings• Generalized bowel distention (earliest sign)• Pneumatosis Intestinalis• Pneumoperitoneum• Large distended immobile loop on repeated x-rays (persistant loop sign-may indicate a gangrenous loop of bowel)• Gasless abdomen (perforation and peritonitis)• Portal venous air07/01/2012 43
  • 43. Complications• Mortality is 30-60%• Stricture formation is 25-35%• Bowel obstruction in 5%• Enterocutaneous fistulas• FTT secondary to short bowel syndrome and malabsorption• Central line sepsis07/01/2012 44
  • 44. Treatment strategies• Suspected NEC (Bell’s stage I)Hold enteral feedsObtain an x-ray to view bowel gas patternGastric decompression with an NG tube to suctionRule out Sepsis with initiation of IV antibiotics07/01/2012 45
  • 45. Treatment Strategies• Definite NEC (Bell’s stage II)Follow serial exams and serial x-rays with left lateral decubitus films to screen for perforation correction of metabolic disturbances(acidosis, hyperkalemia, hyperglycemia etc), hypovolemia, thrombocytopenia, and DICIntubation if neededConsider surgical consult 07/01/2012 46
  • 46. Treatment Strategies• Advanced NEC (Bell’s Stage III)Same management as Stage II with increased monitoring of BP, other vitals)Vigorous fluid resuscitation, inotropes, ventilator supportSurgery as indicated 07/01/2012 47
  • 47. Treatment Strategies • Surgery indication :- Absolute indications 1) pneumoperitoneum 2) intestinal gangrene  Relative indications 1) progressive clinical deterioration 2) fixed abdominal mass, portal vein gas, abdominal wall erythema 3) persistently dilated bowel loop07/01/2012 48
  • 48. Prevention• Antenatal steroids decreased the incidence of NEC• Use of human milk• GI priming with cautious advancement of enteral feeding. 07/01/2012 49
  • 49. Thank youDownload more documents and slide shows on The Medical Post [ www.themedicalpost.net ]