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Neonatal Sepsis
- 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?