This document discusses neonatal sepsis, including: - Definition, epidemiology, pathogenesis, predisposing factors, etiology, classification, clinical symptoms, investigations, evaluation, management, supportive measures, antibiotics used, complications, prevention, and questions. Neonatal sepsis is defined as a clinical syndrome resulting from infection in newborns. It can be early onset (within 3 days of life) or late onset (4 days to 1 month). Common causes are E. coli, Klebsiella, GBS. Management involves early recognition, supportive care, and appropriate antibiotic therapy based on culture results. Outcomes can be improved with prompt diagnosis and treatment.

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?