This document discusses neonatal sepsis and its prevention. It defines neonatal sepsis as infection in infants under 4 weeks old shown through systemic signs. Common causes are E. coli, GBS, and other bacteria. Sepsis can be early onset from maternal exposure or late onset from hospital exposure. Prevention focuses on good antenatal care, infection control in neonatal units like handwashing, and minimizing invasive procedures and equipment sharing between infants. Proper feeding, skin care, and environmental cleaning practices can also help prevent neonatal sepsis.

1. NEONATAL SEPSIS
AND PREVENTION
Dr. Hany Lotfy MD
Ass. Professor of Medical
Microbiology and Immunology
Sulaiman Al Rajhi Colleges

2. Contents
1. Definitions.
2. Etiology of NS.
3. Early onset NS.
4. Late onset NS.
5. Risk of exposure to late neonatal sepsis.
6. Clinical features of NS.
7. Diagnosis and DD of NS.
8. Treatment of NS.
9. Prevention of NS.

3. DEFINITION
Neonatal sepsis (NS) is defined as clinical
syndrome of bacteremia with systemic signs
and symptoms of infection in the first four
weeks of life.

4. ETIOLOGY
Common organisms identified:
1. Escherichia coli.
2. Group B Streptococci.
3. Coagulase negative staphylococci.
4. Streptococcus pneumoniae.
5. Listeria monocytogenes.
6. Klebsiella pneumoniae.
7. Acinetobacter species.
8. Pseudomonas aeruginosa.
9. Candida.

5. EPIDEMIOLOGY
Incidence:
 1-8 cases per 1,000 live births.
Mortality:
 13-70% world wide.
 13-15% of all neonatal deaths (USA) (8th cause).
Morbidity:
 Meningitis occurs in one third of sepsis cases.
Sex:
 Males > Females (2 - 6 times).
Age: premature infants
 Weight 1,000-2,000 gm: 8-9/1,000.
 Weight <1,000 gm: 26/1,000).

6. A. EARLY ONSET
NEONATAL SEPSIS (EONS)

7. • Infection occurring in the first 3 days of life.
• 5-7/1,000 live births.
Exposure can occur:
1. Before delivery:
• Infected amniotic fluid.
• Untreated maternal sepsis.
2. During delivery:
• Organisms in maternal genital tract.
3. After delivery:
• Exposure to external organisms.
4. Environment:
• Suction tubes; ambubags, resuscitoire, O2 masks…

8. Risk factors:
1. Premature rupture of membranes
(PROM).
2. Infection in the mother.
3. Presence of group B Streptococci
(GBS) in the mother.

9. Pathophysiology
1. The infant has acquired the organism during the intra-
partum period from the maternal genital tract.
2. Could be acquired trans-placentally.
3. With rupture of membranes, vaginal flora or various
bacterial pathogens may ascend to reach the amniotic
fluid and the fetus → Chorioamnionitis → fetal
colonization and infection.

10. PRIMARY SITES of colonization:
1. Nasopharynx.
2. Oropharynx.
3. Conjunctiva.
4. Umbilical cord.
Aspiration of infected amniotic fluid by the fetus or
neonate may play a role in resultant respiratory
symptoms.

11. • Early onset NS manifests as:
1. Pneumonia (Frequently)
2. Less commonly as:
• Septicemia.
• Meningitis.

12. The associated factors for EOS
 Low birth weight.
 Prolonged rupture of membranes > 24 hours.
 Foul smelling liquor.
 Multiple PV examinations.
 Maternal fever.
 Difficult or prolonged labour.
 Aspiration of meconium.

13. B. LATE ONSET NEONATAL SEPSIS

14. • Occurs 4 – 7 days after birth.
• Usually due to organisms thriving in the
external environment.
• Presents with:
1.Septicemia.
2.Pneumonia.
3.Meningitis.

15. Risk of exposure to late
neonatal sepsis

16. 1. Lack of hand hygiene by health care givers.
2. Low birth weight.
3. Lack of initiating breast feeding.
4. Skin infections.
5. Aspiration of feeds.
6. Disruption of skin integrity with needle pricks and/or
use of IV fluids.
• These enhance the chances of infection in the
neonates (who have an already poor immune
defense mechanism).

17. Early vs Late Onset NS
Early Onset NS Late Onset NS
Onset <72 hrs >72 hrs
Source Maternal genital tract Environmental (nosocomial)
Risk factor Prematurity, Amnionitis,
Maternal infection
Prematurity
Presentation Fulminant
Pneumonia frequent
Slowly progressive
Septicemia & Meningitis
frequent
Mortality 5-50% 10-15%

18. CLINICAL FEATURES

19. • Manifestations of neonatal sepsis are usually
VAGUE and demand A HIGH INDEX OF
SUSPICION for early diagnosis.

20. Most common manifestations include:
1. Respiratory distress in early onset NS.
2. Altered feeding behavior in a well established feeding
newborn (aspiration, vomiting, etc).
3. Baby who was active, suddenly or gradually becomes
lethargic, inactive or unresponsive and refuses to suckle.
4. Temperature instability: Hypo- or hyperthermia.
5. Skin: Poor peripheral perfusion, cyanosis, pallor, petechiae,
rashes, or jaundice.
6. Metabolic: Hypo- or hyperglycemia or metabolic acidosis.

21. Signs of severe sepsis
• Episodes of apnea or gasping breaths in a baby who was
otherwise stable.
• Diarrhea, vomiting and abdominal distension.
• Cyanosis.
• Shock.
• Others:
– Prolonged capillary refill time > 3 seconds.
– Bleeding.
– Renal failure.

22. Diagnosis of NS

23. A. Non-specific:
• White blood cell count and differential:
– Neutropenia can be a threatening sign (< 1,800/cmm).
– Immature to Total neutrophil (I:T) ratio ≥ 0.2 is predictive
(Normal: ˂ 0.16).
• Acute phase reactants:
– C-Reactive Protein (CRP): rises early.
– ESR rises > 15 mm 1st hr.
• Platelet count:
– Decreases, a late sign and non-specific.
• Others:
– Bilirubin, glucose, sodium.

24. B. Definitive, specific:
• Cultures:
– Blood:
• Confirms sepsis.
– Urine:
• Don’t need in infants <24 hours old because UTIs are
exceedingly rare in this age group.
– CSF:
• Controversial ????
• May be useful in clinically ill newborns or those with
positive blood cultures.

25. Radiology
1. Chest X-Ray:
– For infants with respiratory symptoms.
2. Renal ultrasound:
– For infants with accompanying UTI.
3. CT scan:
– For infants with probable meningitis or seizures.

26. Differential Diagnosis
1. Respiratory distress syndrome (RDS).
2. Metabolic diseases.
3. Hematologic diseases.
4. CNS diseases.
5. Cardiac diseases.
6. Other infections (e.g. ToRCH infections).

27. TREATMENT

28. 1. Antibiotics:
a. Primary sepsis: ampicillin and gentamicin.
b. Nosocomial sepsis: vancomycin and gentamicin.
c. Cefotaxime, if meningitis is suspected.
Should be based on culture & sensitivity

29. 2. Supportive therapy
• Respiratory:
• Oxygen and ventilation as necessary.
• Cardiovascular:
• Support blood pressure with volume expanders.
• Hematologic:
• Treat DIC.
• CNS:
• Treat seizures with phenobarbital.
• Metabolic:
• Correct hypo-/hyperglycemia and metabolic acidosis.

30. PREVENTION OF NEONATAL
SEPSIS

31. 1. Good antenatal care.
2. Maternal infections diagnosed and treated early.
3. Babies should be breastfed early.
4. Infection control policies applied in the unit.

32. GENERAL PRINCIPLES
1. MINIMIZE.
 Handling of neonates.
 Invasive procedures.
 Visitors.
2. Staff should perform hand washing:
 Upon entering and leaving the nursery.
 Between infants.
3. Equipment should not be shared between infants.
4. Practice aseptic techniques.

33. NEONATAL CARE PRACTICES
IV Cannular Insertion:
• Wash hands aseptically.
• Wear gloves.
• Disinfect neonate’s skin.
• Use a no-touch technique.
IV Therapy:
• Certain staff are selected to prepare IV fluids.
• An area should be specified for preparation of medications
and IV fluids.
• Aseptic technique during procedure.

34. SKIN CARE
• Cord should be cleaned/dried.
• Daily washing has no value in
infection control.
• The only time whole body bathing
and antiseptic soaps are indicated is
during an infection outbreak.
• Soiled areas showed be gently
cleaned, avoid damage to the skin.
• Adhesive tapes that damage
neonate’s skin should be avoided.

35. INFANT FEEDING
Maternal/Breast Milk:
• Expressed Breast Milk (EBM) should be
collected into sterile containers and stored
aseptically.
• Hand washing with an antiseptic.
• Breast pump parts in contact with milk should
be washed after each use and sterilized.
• EBM should be stored for not more than 48
hours in a refrigerator.
• Avoid EBM if mother has transmittable
diseases.

36. INFANT FORMULAS
• Formula once prepared should be
used within 4 hours of
uncapping.
• Sterile technique should be
observed during preparation.
• Formulas can be refrigerated for
24 hours and used within 4 hours
of opening.

37. EQUIPMENTS
• Incubators and ventilators: cleaned and
disinfected in between patients.
• Incubators: disinfected every 5 days (H2O2
or isopropyl alcohol 70%).
• Equipments in direct contact with
neonatal mucous membranes: disinfected
and sterilized between patients.
• Sterile water should be used in nebulizers
and humidifiers.

38. ENVIRONMENTAL CLEANING
• Daily surface cleaning with water and detergent.
• Blood spills should be removed immediately with a
disinfectant.
• Walls, windows, doors, curtains should be cleaned
regularly.

39. ISOLATION
• Studies have shown NO NEED or added benefit
for isolation rooms.
• The need however only arises in:
Airborne transmittable infections.
Infants of mothers with perinatal Varicella (Single room
isolation).

40. BARRIER PRECAUTIONS
GLOVES:
• Indicated in heavy microbial load such as
infectious diarrhea, Enterovirus, Hepatitis
A, and Rotavirus.
GOWNS:
• Of no benefit in reduction of neonatal
infections.
• Not cost-effective.

41. HAND HYGIENE
• Hand hygiene before and after
every patient is the SINGLE
most important means of
reducing risk and preventing
spread of infections in
hospitals.

42. Aseptic or alcohol based hand-rub
Should be performed:
1. Before entering the neonatal unit.
2. Before invasive procedures.
3. Before use of multi-dose drug vials.
4. Before mixing IV fluids.
5. Before administration of IV medications.