Neonatal sepsis is a deadly disease prevailing worldwide

1. NEONATAL SEPSIS
DR. MUHAMMAD BABAR AHMED
PEADS UNIT 2

2.  A 2 week old infant presents with irritability, fever, poor feeding and grunting.
Examination reveals a bulging fontanel, delayed capillary refill and tachypnea
 What is the diagnosis?

3. Definition
 It is defined as a clinical syndrome of Systemic Illness resulting from metabolic
and circulatory collapse from infection in newborns.
 It is an important cause of mortality and morbidity in newborns especially in
LBW babies and preterm infants
 Early onset presents within 3 days of life
 Late onset occurs between 4 days up to one month of age

4. Epidemiology
 The Incidence in Pakistan is about 1-10/1000 live births and even rises to 22/1000
live births in developing countries.
 80% neonatal deaths are reported to be from sepsis
 In Pakistan the infant mortality Rate is 78/1000 and perinatal mortality rate
is 60/1000
 But If Diagnosed early and with the start of appropriate antibiotics sepsis can be
saved

5. Pathogenesis
 When pathogenic bacteria gain access into the bloodstream, they may cause an
array of overwhelming infection ( septicemia)
 The common sites of localization for these bacteria are either the lungs (
pneumonia) or the meninges ( Meningitis)

6. Predisposing Factors
 There are two major predisposing factors which are either Host/ Newborn related
or Maternal factors
 Host Related Factors
 Impaired Cellular response in which the newborn is unable to adequately concentrate cells of
inflammation
 Or impaired Humoral Immune response
 Maternal factors
 LBW
 Maternal Illness at the time of labour
 Prolonged Rupture of membranes
 Maternal Amnionitis or chorioamnionitis

7. Environmental Factors
 Environmental Factors also play an important role some of these are
 Home delivery leading to inappropriate aseptic measures
 Low Birth weight
 Birth asphyxia
 Bacterial contamination at time of birth
 Prematurity
 Bottle Feeding

8. Etiology
 E. Coli
 Klebsiella
 Psuedomonas
 Group B streptococcus
 Staphylococcus
 Proteus

9. Classification
 Neonatal Sepsis
Early
Onset
Sepsis
Late Onset
Sepsis

10. Early Onset Sepsis
 It mainly occurs due to bacteria occurred before and during delivery that is mainly
caused by the organisms mainly prevalent in the genital and the urinary tract
 It is mostly caused by Gram –ve bacteria eg. E. Coli,
Klebsiella, Enterobacter, Group b Streptococci
 And majority of these patients present with Respiratory Distress due to
intrauterine pneumonia

11. Late Onset Sepsis
 It is caused by organisms of the external environment, either acquired from the
hospital or from the home
 Often transmitted through the hands of the people handling or the health care
providers
 Is also caused by Gram –ve organisms, Gram +ve organisms are also involved
 May present with septicemia, pneumonia or meningitis

12. Clinical Symptoms
 The Clinical spectrum at the beginning of the disease is Usually non specific
 Generally it starts as
 Refusal to feed
 Lethargy
 Poor temprature control
 Poor peripheral perfusion
 Tachycardia or Bradycardia
 Hypotonia or bulging of fontanelle
 Irritability
 Seizures
 Vomiting or diarrhea
 Jaundice purpura or impetigo

13. Symptoms According to Systems
 General:
 Fever, Poor Feeding, Edema
 Neurological:
 Irritability, lethargy, Hypotonia, Abnormal Moro reflex, Irregular
respiration, Seizures, Bulging of fontanelle
 Respiratory:
 Apnea, Tachypnea, Retractions, Flaring, Grunting, Cyanosis
 Cardiac:
 Pallor, Mottling of skin, Hypotension, Tachycardia or Bradycardia

14. Continued
GIT:
Vomiting, Diarrhea, abdominal distention, Hepatomegaly, Septic Umbilicus
Renal & Hematological:
Oliguria, Jaundice pallor mottling of skin, petechia, purpura

15. Investigations
 First we will move on with the specific or definitive tests
 Blood culture from fresh umbilical artery
 CSF Culture
 Urine Culture
 Tracheal aspirate Culture and gram stain
 Other Non specific /Diagnostic / Supportive tests include
 CBC special focus on elevated WBC count and low platelet count
 Elevated ESR & CRP
 CXR especially for children with RDS

16. Evaluation of the extent of Disease
 Evaluation of the extent of the disease is done on the basis of
 LP to evaluate for meningitis
 Urine examination to evaluate for UTI
 CXR to evaluate for pneumonia
 Stool Occult for GI Bleeds

17. Management
 The three basic Principles of management are
 Early Recognition of the disease
Optimal Supportive
Measures
Appropriate Antibiotic
Therapy

18. Management Of Early Onset Sepsis
 First Line drugs used for sepsis are Ampicillin (100mg/kg/day) in 8 hourly doses
the dose is doubled for meningitis
 Amikacin(15mg/kg/day) OD if the neonate is of less than 7 days and BD if older
than 7 days
 Gentamycin (7.5mg/kg/day) divided in 8 or 12 hourly doses
 The choice of antibiotics is always according to the blood culture and sensitivity
once the results are available. Empirical therapy is then stopped
 Resistant strains are treated with Vancomycin
 Duration of treatment is for almost 10 days for bacteremia

19. Supportive Measures
 Nursing care with ambient temperature
 Appropriate IV fluids according to the requirements
 Correct hypoglycemia with dextrose water
 Vitamin K twice a week Until enteral feed is started
 Bicarbonates to treat metabolic acidosis
 If in state of shock treat with dopamine (7-15 ug/kg) and volume expanders
 Corticosteroids to treat adrenal insufficeincy
 Phototherapy if hyperbilirubenemia is present
 Appropriate anti epileptics for seizures
 If Bleeding tendency is present then FFP, Platelets or fresh blood transfusion according to indices

20. Late onset sepsis
 In Late onset sepsis the drugs of choice are
 Vancomycin and Aminoglycoside
 Vancomycin (15mg/kg/day) given 8 hourly
 Amikacin ( 15mg/kg/day) divided in 12 hourly doses
 Duration depends on the culture report, pathogen and site of infection
 If fungal infection are suspected then Amphotericin B is given
 Ceftazidime is given for Psuedomonas Coverage
 Supportive measures are according to the requirements

21. Newer Therapies
 IVIG is a new mode of therapy studies are undergoing but there has been no
proven benefit till yet
 GM-CSF can be used as a modality of therapy or prevention to

22. Complication of Sepsis
 Endocarditis
 Septic emboli
 Septic joints
 Osteomyelitis
 DIC
 Organ failure

23. Prevention
 Maternal vaccination against vaccine preventable diseases like rubella and
vericella
 Aggressive management of chorioamnionitis with appropriate antibiotics
 As for the prognosis case fatality rate is 20-50%

24. Questions
A full term one weel old infant presents with fever, poor feeding and a bulging
fontanel. Mother has history of prolonged rupture of membranes and a low grade
fever. Spinal Fluid of infant demonstrates Gram positive cocci. CSF is turbid and
examination shows a low glucose.
Give the diagnosis?
Is it early or late onset sepsis?
How will you manage the patient?