2. SEPSIS
Sepsis (the presence of microorganisms or their
toxins in the blood or other tissues) continues to be
one of the most significant causes of neonatal
morbidity and mortality. Maternal immunoglobulin M
(IgM) does not cross the placenta Immunoglobulin
A (IgA) and IgM require time to reach optimum
levels after birth.
Dysmaturity seen with intrauterine growth restriction
(IUGR) and preterm and postdate birth further
compromises the neonate’s immune system.
3. 2 PATTERNS OF NEONATAL BACTERIAL INFECTION
ACCORDING TO THE TIME OF PRESENTATION
1. Early-onset or congenital sepsis usually
manifests within 24-48 hours of birth, progresses
more rapidly than later-onset infection, and carries
a mortality rate as high as 50%.
Caused by:
Microorganisms from the normal flora of the maternal
vaginal tract including group B streptococci, Hemophilus
influenzae, Listeria monocytogenes, Escherichia
coli, and Streptococcus pneumoniae.
E.coli and Coagulase negative staphylococcus has
been reported to be most common offending pathogen
in early-onset sepsis
4. HX OF OBSTETRIC EVENTS IN EARLY-ONSET
Such as:
Preterm Labor
Prolonged Rupture of membranes(>18hrs)
maternal fever during labor
and chorioamnionitis
5. 2. Nasocomial infection (Late-onset) is most
commonly seen after 2 weeks of age and is lower in
progression.
Bacteria responsible for late-onset sepsis are
varied, may be acquired from birth canal from the
external environment, and include Staphylococcus
aureus, Staphylococcus epidermidis, Pseudomonas
organisms, and group B streptomocci.
6. RISK FACTORS FOR NEONATAL SEPSIS
SOURCE
RISK FACTORS
Maternal
Low socioeconomic status
Poor prenatal care
Poor nutrition
Substance abuse
Intrapartum
Premature rupture of membranes
Maternal fever
Chorioamnionitis
Prolonged labor
Rupture of membranes >12 -18hr
Premature labor
Maternal urinary tract infection
7. CONT.
SOURCE
RISK FACTORS
Neonatal
Twin or multiple gestation
Male
Birth asphyxia
Meconium aspiration
Congenital anomalies of skin or
mucuos membranes
Galactosemia
Absence of spleen
Low birth weight or prematurity
Malnourishment
Prolonged hospitalization
8. Viral Infections may cause miscarriage, stillbirth,
intrauterine infection, congenital malformations, and
acute neonatal disease.
It is important to recognize the manifestations of
infections in the neonatal period to be able to treat
the acute infection to prevent nasocomial infections
in other infants, and to anticipate effects on the
infant’s subsequent growth and development.
9. Fungal Infections are of greatest concern in the
immunocompromised or premature infant.
Occationally, fungal infections such as thrush are
found in otherwise healthy term infants.
Septicemia refers to a generalized infection in the
bloodstream. Pneumonia, the most common form
of neonatal infection, is one of the leading causes
of perinatal death. Bacterial meningitis affects 1 in
2500 live-born infants. Gastroenteritis is sporadic,
depending on epidemic outbreaks.
10. Local infections such as conjunctivitis and
omphalitis occur commonly.
Infection continues to be a significant factor in fetal
and neonatal morbidity and mortality.
11. SIGNS OF SEPSIS
SYSTEM
SIGNS
Respiratory
Apnea, bradycardia
Tachypnea
Grunting, nasal flaring
Retractions
Decreased oxygen saturation
Metabolic acidosis
Cardiovascular
Decreased cardiac output
Tachycardia
Hypotension
Decreased perfusion
Central nervous
Temperature instability
Lethargy
13. SUSPECTED NEONATAL SEPSIS
ASSESSMENTS
1. Potential maternal risk factors and unstable vital signs, especially temperature
instability
2. Sepsis screen in first hour (CBC with differential, platelets, and CRP level) if
there are significant maternal risk factors (Prolonged rupture of membranes, maternal temperature) or if
infant demonstrates physiologic signs of sepsis.
TREATMENT
1.Start IV administration of antibiotics by peripheral IV
2.Provide other treatments as needed for additional physiologic problems
(supplemental oxygen or ventilator for respiratory distress, incubator for temperature instability)
POSSIBLE
1. Neonatologists and advanced practice nurses for care unstable infants
CONSULTATIONS 2. Medical specialists for care of infants with additional problems (congenital
deformities
3. Lactation consultant, interpreter, social worker, and chaplain as needed or
requested
ADDITIONAL
1. Weight and measurements
ASSESSMENTS
2. Blood culture, chest x-ray, urinalysis, and lumbar puncture, if infant is
symptomatic or CRP level is positive
3. Repeat determination of CRP level in the morning for 2days; if negative and
infant not symptomatic, stop antibiotic treatment
4. Continuous cardiac and oxygen saturation monitor assessment if infant’s
condition is unstable
DIRECT INFANT 1.Vital signs every 1 to 2 hr for the first 4 hr, then every 4hr
CARE
2. Advance oral feedings as tolerated (infant NPO only if condition is
physiologically unstable)
3. Bath and cord care done per unit protocols
TEACHING AND 1. Initiate on admission. Provide parents with written and oral information on
DISCHARGE
suspected sepsis
PLANNING
2. Reinforce information and determine parents’ understanding of information
before discharge. Include information on well-baby care and community
follow-up with the family’s primary health care provider
14. CASE MANAGEMENT
ASSESSMENT
The prenatal record is reviewed for risk factors
associated with infection and the signs and symptoms
suggestive of infection.
Maternal vaginal or perineal infection may be
transmitted directly to the infant during passage through
the birth canal.
Perinal events also reviewed. Premature rupture of
membranes (PROM) may be caused by maternal or
intrauterine infection. Ascending infection may occur
after prolonged PROM, prolonged labor, or intrauterine
fetal monitoring.
15. A maternal history of fever during labor or the presence
of foul-smelling amniotic fluid may also indicate the
presence of infection.
Sepsis occurs about twice as often and results in a
higher mortality in male than female infants. The
neonate assessed for respiratory distress, skin
abscesses, rashes, and other indications of infection.
The earliest clinical signs of neonatal sepsis are
characterized by lack of specificity. The nonspecific
signs include:
Lethargy
Poor weight gain
Irritability
16.
Laboratory Studies are important. Specimens for
cultures include:
Blood
CSF
Stool
Urine
Fluids such as urine and CSF may be evaluated by
Counterimmune electrophoresis (CIE) or
Latex Agglutination (LA) to assist in the identification of
the bacteria. A complete blood cell count with
deferential is performed to determine the presence of
bacterial infection or increased in WBC count
17. The total neutrophil count, immature to total
neutrophil (I:T)ratio, absolute neutrophil count
(ANC), and C-reactive protein may be used to
determine the presence of sepsis.
Advances in technology include detection of viral
DNA or antibodies by polymerase chain reaction
(PCR) amplification in fluids.
Treatment with antibiotics is initiated after cultures
are obtained in neonates; in high risk infants with
significant illness antiviral or antibiotic treatment
may begin once cultures are obtained and once the
pathogen is identified antibiotic therapy may be
modified.
18.
NURSING DIAGNOSES
Examples of nursing diagnoses related to neonatal
infections include the following:
NEWBORN
Risk for in fection related to
Maternal vaginal (or other) infection
Indwelling umbilical catheters, parenteral fluids (invasive
procedures)
Intrauterine electronic fetal monitoring
Dysmaturity, IUGR, gestational age
19.
Ineffective thermoregulation related to
Impaired skin integrity related to
systemic infection
use of multiple supportive invasive measures (e.g, physiologic
monitoring, parenteral fluid therapy, inhalation therapy)
Acute pain related to
Multiple supportive invasive measures
20. PARENTS AND FAMILY
Anxiety, fear, or anticipatory grieving related to
Uncertainty about infant’s prognosis
Therapy (invasive)
Risk for impaired parent-infant attachment related to
Separation of parent and newborn
Feelings of inadequacy in caring for infant
Powerlessness or spiritual distress related to
Perinatal events or newborn’s condition beyond parent’s
control
21. EXPECTED OUTCOMES
Include the following:
The newborn will remain free of infection
The newborn’s early signs of sepsis will be recognized,
and appropriate therapy will be instituted.
If therapy is necessary, the newborn will suffer no
harmful sequelae.
Parents will begin interacting and caring for newborn
and be involved in his or her care.
Parents will maintain self-esteem by understanding that
their role as parents is important to the infant’s wellbeing.
22. PLAN OF CARE AND IMPLEMENTATION
Prevention
Virtually all controlled clinical trials have demonstrated
that effective handwashing is responsible for the
prevention of nosocomial infection in nursery units.
Measures to be taken include Standard Precautions,
careful and thorough cleaning of contaminated
equipment, frequent replacement of used equipment
(e.g, changing intravenous and nasogastric tubing per
hospital protocol, and cleaning resuscitation, ventilation
equipment, intravenous pumps, and incubators), and
disposal of contaminated linens and diapers in an
appropriate manner.
Overcrowding must be avoided in nurseries.
23.
Infants cared for in NICUs are at high risk for infection.
Handwashing is the single most effective measure to reduce
nosocomial infection.
The combined use of alcohol, hand hygiene, and gloves is
effective in reducing the incidence of systemic infection.
Antibiotic is instilled into newborn’s eyes 1 to 2 hours after
birth to prevent infection
The skin, its secretions, and normal flora are natural defense
that protect against invading pathogens
Studies indicate that cords cleaned with sterile water or those
left to dry naturally separate more quickly than those cleaned
with alcohol, and neither method resulted in an increased
number of infections. (sterile water and neutral Ph cleanser)
