Neonatal infections


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Neonatal infections

  1. 1. NEONATAL INFECTIONS REPORT BY: Toliao, Mirelle M. BS-Nursing
  2. 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. 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. 4. HX OF OBSTETRIC EVENTS IN EARLY-ONSET  Such as: Preterm Labor  Prolonged Rupture of membranes(>18hrs)  maternal fever during labor  and chorioamnionitis 
  5. 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. 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. 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. 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. 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. 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. 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
  12. 12. CONT. SYSTEM SIGNS Hypotonia Instability, seizures Gastrointestinal Feeding intolerance (decreased Suck strength and intake; increasing residuals) Abdominal distention Vomiting, diarrhea Integumentary Jaundice Pallor Petechiae Mottling
  13. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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)