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Neonatal Sepsis, Necrotizing        Enterocolitis                                   Dr. Kalpana Malla                     ...
Neonatal SepsisClinical    syndrome   of    bacteraemia  characterized by   systemic signs and  symptoms of infection in t...
IncidenceIn India  - 3.9 % of all imtramural births  - 20 – 30 % develop meningitisIn developed countries   - 1 in 1000 li...
EtiologyCommon -  E.coli, Klebsiella, Pseudomonas, Proteu  s,Others- Staph. aureus, streptococcus  ssp, acintobactor, H.  ...
Maternal Risk Factors1. Intrapartum - Maternal Infection      - Purulent / foul smelling liquor      - Fever (>380C)      ...
Neonatal Risk factors  1. Low Birth Weight Baby/Preterm  2. Perinatal asphyxia  3. Male gender                            ...
CLASSIFICATION1. Early onset –• < 72hrs of age - Before or during deliveryⓐ PROM →Ascending Chorioamninitisⓑ During passag...
CLASSIFICATION2. Late-onset• >72hrs-30 days of age mostly end of 1st week.ⓐ Nosocomial infection/Hospital inf.    Source: ...
CLASSIFICATIONⓑ Community infection  • After discharge from hospital Source - mother, family, contacts, baby care units,Or...
CLASSIFICATION3. Late-late onset• After 30 days of ageOrganisms-   saph.  epidermidis, E.coli, candida, Tuberculosis  Viru...
Early vs Late onset sepsis               Early onset       Late onsetAge          <72 hours           >72 hoursRisk factor...
Symptoms of Neonatal Sepsis1. CNS   Lethargy, Refusal to suck, Limp, Meningitis seen in 1/3 of all cases-    bulging fonta...
Symptoms of Neonatal Sepsis4.GIT         Vomiting, Diarrhoea, Abdominal distension, NEC,blood in stool5.HaematologicalBlee...
SEPSIS SCREENAt BirthMajor risk factors     1. Rupture of membranes > 24 hrs     2. Maternal intrapartum fever > 100.40 F ...
Minor risk factorsMinor risk factors     7.Foul smelling liquor/ meconium stained     8.Maternal WBC Count >15,000     9.M...
Laboratory Diagnosis of NNS1. Direct methods           - Blood culture           - CSF culture           - Urine culture2....
2. Indirect methods / Screening tests     - Acute phase reactants- CRP - positive    - Buffy coat examination   - Smear of...
Lab diagnostic criteria• Septic screen- if 3 are abnormal chance of  infection 90%A) TLC>20,000 or <5000B) Bands >20% or b...
Management of Neonatal Septicemia1. Antibiotic Therapy2. Supportive Therapy3. Immunotherapy
Antibiotic Therapy• Antibiotic started on clinical grounds tillC/S  reports: Initial choice**EOS – Aminoglycoside + Ampici...
Supportive care:•   IV fluids, glucose,•   Vit K, anticonvulsants•   Blood transfusion,•    Shock-Dopamine, Dobutamine,Ste...
Immunotherapy• IVIG• Exchange blood transfusion - if there is  sclerema, DIC, Neutropenia• Granulocyte transfusion - Colon...
Natural course of sepsis                               Bacteria             Focal infection                        Bactera...
Evaluation of symptomatic infant for sepsis               - Sepsis screen               - Chest X-ray               - Lumb...
Superficial Infections     -   Pustules - After puncturing, clean with                   betadine and apply antimicrobial ...
Prevention of Infection             -   Exclusive breastfeeding             - Keep cord dry             - Hand washing by ...
Hand Washing   - Single most important means of      preventing nosocomial infections                - Very Simple        ...
Hand Washing             - Two minutes, hand washing to be done               before entering baby care area             -...
Steps of effective hand washing- Roll sleeves above elbow    - Remove wrist watch, bangles, ring etc    - Using plain wate...
Steps of Effective Hand Washing                 - Keep elbow always dependent                 - Close the tap using elbow ...
NECROTIZING ENTEROCOLITIS             Definition   • An idiopathic coagulation     necrosis and inflammation of the     in...
Incidence• 0.5 - 3.5/1000 live births• Affects mostly premature infants (10% occur in FT)• Increased incidence with decrea...
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...
Risk Factors• low APGARS,• UAC• severe RDS,• PDA’s (ie gut ischemia),• Aggressive and early enteral feeding in a premature...
Clinical Manifestations   • Bell’s staging criteria   Stage I (suspected NEC)   Stage II (definite NEC)   Stage III (advan...
Clinical manifestations   • Stage I   • Systemic signs       • Temp instability   • Intestinal Signs     • Mild abdominal ...
Clinical Manifestations     Stage II   • Systemic signs      • Same as Stage I with                           metabolic ac...
Clinical Manifestations   Stage III (A & B)   • Systemic signs     • Same as II plus                          hypotension,...
07/01/2012   40
07/01/2012   41
07/01/2012   42
Radiologic findings• Generalized bowel distention (earliest sign)• Pneumatosis Intestinalis• Pneumoperitoneum• Large diste...
Complications•    Mortality is 30-60%•    Stricture formation is 25-35%•    Bowel obstruction in 5%•    Enterocutaneous fi...
Treatment strategies• Suspected NEC (Bell’s stage I)Hold enteral feedsObtain an x-ray to view bowel gas patternGastric ...
Treatment Strategies• Definite NEC (Bell’s stage II)Follow serial exams and serial x-rays with left lateral decubitus  fi...
Treatment Strategies• Advanced NEC (Bell’s Stage III)Same management as Stage II with increased  monitoring of BP, other ...
Treatment Strategies       •      Surgery indication :-             Absolute indications              1) pneumoperitoneum...
Prevention• Antenatal steroids decreased the incidence of NEC• Use of human milk• GI priming with cautious advancement of ...
Thank youDownload more documents and slide shows on The    Medical Post [ www.themedicalpost.net ]
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  1. 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. 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. 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. 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. 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. 6. Neonatal Risk factors 1. Low Birth Weight Baby/Preterm 2. Perinatal asphyxia 3. Male gender 07/01/2012 6
  7. 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. 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. 9. CLASSIFICATIONⓑ Community infection • After discharge from hospital Source - mother, family, contacts, baby care units,Organisms: • Strepto pneumoniae • Tuberculosis • Viruses
  10. 10. CLASSIFICATION3. Late-late onset• After 30 days of ageOrganisms- saph. epidermidis, E.coli, candida, Tuberculosis Viruses
  11. 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. 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. 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. 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. 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. 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. 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. 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. 19. Management of Neonatal Septicemia1. Antibiotic Therapy2. Supportive Therapy3. Immunotherapy
  20. 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. 21. Supportive care:• IV fluids, glucose,• Vit K, anticonvulsants• Blood transfusion,• Shock-Dopamine, Dobutamine,Steroids• Phototherapy, Oxygen• Hypoglycemia: 10% dextrose• FFP• Ventilatory support
  22. 22. Immunotherapy• IVIG• Exchange blood transfusion - if there is sclerema, DIC, Neutropenia• Granulocyte transfusion - Colony Stimulating Factors• Prognosis-upto 50% mortality
  23. 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. 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. 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. 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. 27. Hand Washing - Single most important means of preventing nosocomial infections - Very Simple - Cheap07/01/2012 28
  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. 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. 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. 31. NECROTIZING ENTEROCOLITIS Definition • An idiopathic coagulation necrosis and inflammation of the intestine in a neonate.07/01/2012 32
  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. 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. 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. 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. 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. 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. 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
  39. 39. 07/01/2012 40
  40. 40. 07/01/2012 41
  41. 41. 07/01/2012 42
  42. 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. 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. 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. 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. 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. 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. 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. 49. Thank youDownload more documents and slide shows on The Medical Post [ www.themedicalpost.net ]
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