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6 Neonatal Septicemia


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6 Neonatal Septicemia

  1. 1. Neonatal Septicemia
  2. 2. Will They Have Good Future ???
  3. 3. Objectives What will I learn? Etiologies and risk factors Symptoms Diagnosis Treatment
  4. 4. Introduction <ul><li>Common </li></ul><ul><li>-20% of VLBW has sepsis </li></ul><ul><ul><li>-In term 0.1% </li></ul></ul><ul><ul><li>-Inter-institution difference 11-32% </li></ul></ul><ul><ul><li>(NICHD net work) </li></ul></ul><ul><li>Serious </li></ul><ul><ul><li>-mortality is 3-5 times more for infant </li></ul></ul><ul><ul><li>with sepsis in NICU </li></ul></ul>
  5. 6. What is Neonatal Sepsis? <ul><li>Neonatal Septicemia is a generalized </li></ul><ul><li>infection characterized by the proliferation </li></ul><ul><li>of organisms in the blood circulation during </li></ul><ul><li>the first month of life. </li></ul>
  6. 7. Some basic definitions <ul><li>SIRS(systemic inflammatory response syndrome ) </li></ul><ul><li>- fever, tachypnoea, tachycardia, abnormal WBC </li></ul><ul><li>Sepsis- systemic response to infection </li></ul><ul><li>Severe sepsis- sepsis with organ dysfunction, hypotension </li></ul><ul><li>Septic shock- severe sepsis with multiorgan dysfunction </li></ul><ul><li>difficult to apply these definitions and a staging system to the newborn </li></ul>
  7. 8. Pathogen <ul><li>Staphylococcus </li></ul><ul><li>Escherichia coli </li></ul><ul><li>Conditional pathogen </li></ul><ul><li>Group B streptococcus </li></ul>
  8. 9. Staphylococcus
  9. 10. E. Coli
  10. 11. <ul><li>Staphylococcus epidermidis </li></ul>
  11. 12. <ul><li>Pseudomonas aeruginosa </li></ul>
  12. 13. Klebsiella
  13. 14. <ul><li>Clostridium perfringens </li></ul>
  14. 15. Group B -hemolytic streptococcus
  15. 16. Route of Infection <ul><li>Prenatal infection </li></ul><ul><li>infection during delivery </li></ul><ul><li>postnatal infection </li></ul>
  16. 17. Sepsis Risk Factors <ul><li>Prematurity </li></ul><ul><li>Birth weight </li></ul><ul><ul><li>Term 0.1% </li></ul></ul><ul><ul><li>1,000 -1,500 g 10% </li></ul></ul><ul><ul><li><1,000 g 35% </li></ul></ul><ul><ul><li><750 g. 50% </li></ul></ul><ul><li>Delay enteral feeding and Prolonged TPN </li></ul>
  17. 18. <ul><ul><ul><li>Risk Factors (maternal and neonatal) </li></ul></ul></ul><ul><ul><ul><li>Major </li></ul></ul></ul><ul><ul><ul><ul><li>Maternal prolonged Rupture of Membranes >24 hours </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Intrapartum maternal fever >38 C (>100.4 F) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Chorioamnionitis </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Sustained Fetal Tachycardia >160 beats per minute </li></ul></ul></ul></ul><ul><ul><ul><li>Minor </li></ul></ul></ul><ul><ul><ul><ul><li>Intrapartum maternal fever >37.5 C (>99.5 F) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Twin Gestation </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Premature infant (<37 weeks) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Maternal Leukocytosis ( White Blood Cell count >15000) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Rupture of Membranes > 12 hours </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Tachypnea (<1 hour) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Maternal Group B Streptococcus Colonization </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Low APGAR (<5 at 1 minute) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Low birth weight (<1500 grams) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Foul lochia </li></ul></ul></ul></ul>
  18. 19. What makes a neonate’s immune system susceptible to sepsis? Maturity Immaturity or
  19. 20. You’re Right!!!! The immaturity of a neonate’s immune system makes them MORE SUSCEPTIBLE to sepsis.
  20. 21. Why are newborns so vulnerable to infection? Non-specific immunity Specific immunity
  21. 22. 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
  22. 23. <ul><li>Poor skin barrier </li></ul>
  23. 24. <ul><li>Umbilical stump </li></ul>
  24. 25. <ul><li>Poor blood-brain barrier </li></ul>
  25. 26. Classification <ul><li>Early onset sepsis (EOS): </li></ul><ul><ul><li>bacteria acquired before and during delivery </li></ul></ul><ul><ul><li>5-7/1000 live birth </li></ul></ul><ul><ul><li>1.5% of VLBW infants had EOS (intrapartum antibiotics) </li></ul></ul><ul><li>Late onset sepsis (LOS): </li></ul><ul><ul><li>bacteria acquired after delivery (Nosocomial or community) </li></ul></ul><ul><ul><li>20% of VLBW infants </li></ul></ul>
  26. 27. 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
  27. 28. Symptoms of Neonatal Sepsis The symptoms of are not concrete and vary widely Tachypnea Heart Rate Changes Feeding difficulties Difficulty Breathing Temperature Instability J aundice Irritability
  28. 29. Omphalitis
  29. 30. Bleeding tendency Poor perfusion
  30. 31. Enlargement of liver and spleen
  31. 32. toxical paralytic ileus
  32. 33. NEC
  33. 34. NEC
  34. 35. dyspnea
  35. 36. 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
  36. 37. Clinical manifestation The symptoms are so broad , non-specific , and acute deterioration , How to make a diagnosis as early as possible ?
  37. 38. Laboratory studies <ul><li>Evidence for inflammation </li></ul><ul><li>Evidence for infection </li></ul><ul><li>Evidence for multiorgan system disease </li></ul>
  38. 39. Laboratory Examination: CBC <ul><li>WBC<5×10 9 /L or WBC>20× 10 9 /L </li></ul><ul><li>I/T≥0.2 , toxic granules </li></ul><ul><li>thrombocytopenia <100×10 9 /L </li></ul>
  39. 40. Reference values for neutrophilic cells Manroe BL, J Pediatr 1979;95:89-98.
  40. 41. Total neutrophils Immature neutrophil I/T ratio
  41. 43. Lab examination:CRP <ul><li>CRP </li></ul><ul><li>α1-AG </li></ul><ul><li>α1-AT </li></ul>
  42. 44. 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
  43. 45. Summary Is there a diagnostic marker for neonatal sepsis?
  44. 46. Great answer! You’re correct! <ul><li>There is NOT a specific diagnostic marker, only determinants of infection </li></ul>
  45. 47. Summary <ul><li>The best approach for diagnosis of systemic bacterial infection: </li></ul><ul><li>use of multiple markers (e.g. CRP, IL-6, TNF  , CD64), and </li></ul><ul><li>serial measurements </li></ul>
  46. 48. Diagnosis <ul><li>history </li></ul><ul><li>– high risk factors </li></ul><ul><li>clinical manifestation </li></ul><ul><li>--nonspecific S/S </li></ul><ul><li>lab results </li></ul><ul><li>- abnormal blood routine, </li></ul><ul><li>CRP, positive culture </li></ul><ul><li>or detection of organisms </li></ul>
  47. 49. Therapy <ul><li>Infection should be the first thought when an infant has symptoms </li></ul><ul><li>Aggressive treatment should begin before the diagnosis is confirmed. </li></ul><ul><li>Therapy can be discontinued if sepsis is excluded </li></ul>
  48. 50. Treatment  Antibiotics therapy  management of complications  supporting therapy  Clearance of infectious focus  Immunotherapy
  49. 51. Antibiotic therapy <ul><li>using antibiotics as early as possible </li></ul><ul><li>choose antibiotics according to drug sensitivity </li></ul><ul><li>giving drugs intravenously </li></ul><ul><li>combine effective drugs to make synergism </li></ul><ul><li>enough therapeutic course </li></ul><ul><li>consider the possible side effects </li></ul>
  50. 52. Dosages of antibiotics for newborns
  51. 53. Supporting therapy <ul><li>Nursing care </li></ul><ul><li>--warm environment </li></ul><ul><li>--oxygen supply </li></ul><ul><li>correction of acidosis and electrolyte disturbance </li></ul><ul><li>fluid , glucose and nutrition balance </li></ul>
  52. 54. Management of complications <ul><li>Shock </li></ul><ul><li>DIC </li></ul><ul><li>Cerebral edema </li></ul><ul><li>Pulmonary hemorrhage </li></ul>
  53. 55. Immunotherapy <ul><li>IVIG </li></ul><ul><li>Exchange transfusion </li></ul><ul><li>Granulocyte transfusion , G-CSF </li></ul><ul><li>Platelet transfusion </li></ul>
  54. 56. Questions <ul><li>Could prophylatic IVIG reduce the morbidity and mortality of neonatal sepsis? </li></ul><ul><li>Might prophylatic IVIG interfere the development of the neonatal IM system? </li></ul>
  55. 57.