This document discusses neonatal infections including neonatal sepsis and ophthalmia neonatorum. It covers factors that make newborns susceptible to infection, modes of transmission from mother to newborn, classifications of neonatal infections, clinical signs and symptoms, management including treatment with antibiotics, and localized infections like umbilical cord infections and skin infections. It provides details on early onset sepsis within 3 days of life typically from maternal sources and late onset sepsis after 3 days often from hospital-acquired infections. Ophthalmia neonatorum refers to conjunctivitis in newborns with bacterial causes like gonorrhea and chlamydia requiring prompt treatment to prevent vision loss.

1. NEONATAL INFECTIONS-
NEONATAL SEPSIS,
OPTHALMIA NEONATRUM
PRESENTED BY:
LIPI MONDAL
M.SC NURSING , 2 ND YEAR STUDENT

2. FACTORS SPECIFIC TO NEONATAL
INFECTIONS
• Diverse modes of transmission of infectious agents from mother to fetus
or newborns during prenatal, or natal or postnatal period.
• Newborns may be less capable of responding to infections because of
one or more of immunologic deficiencies.
• Co-existing conditions often complicate the diagnosis and treatment of
neonatal infections like RDS, congenital pneumonia ,CHD.

3. CONTD…
• The extremely variable clinical manifestations of infectious diseases of
newborns that may present as mild or severe manifestation of focal or
systemic infections.
• The maternal infection is often undiagnosed during pregnancy as the
mother is asymptomatic or non specific signs and symptom during acute
infection.
• The wide variety of etiologic agents that infect newborns like bacteria, virus,
etc.
• The immature LBWN remain in the hospital for long period that put them at
continuous risk of nosocomial infection.

4. PORTALS OF ENTRY OF NEONATAL
INFECTIONS:
1. INTRA-UTERINE (TRANS-PLACENTAL):
a. MATERNAL BLOOD STREAM
b. ASCENDING INFECTION DUE PROLONGED RUPTURE OF MEMBRANES
C. PROLONGED LABOR AND REPEATED PV EXAM.
2. DURING PASSAGE OF THE NEONATE THROUGH INFECTED BIRTH CANAL:
3. POSTNATALLY ACQUIRED (NOSOCOMIAL):
• VIRAL INFECTIONS
• CONGENITAL
• PERINATAL
• BACTERIAL INFECTIONS

5. MODE OF INFECTION
• ANTENATAL PERIOD:
Antenatal infections may occur due to various micro-organisms & described with an
acronym of STORCH where in:
• S- SYPHILIS
• T- TOXOPLASMOSIS
• O- OTHER(GONOCOCCI INFECTIONS, TUBERCULAR INFECTIONS, MALARIA,
VARICELLA, HEPATITIS B, HIV)
• R- RUBELLA
• C- CYTOMEGALO VIRUS
• H- HERPES SIMPLEX VIRUS

6. • INTRA-NATAL PERIOD:
• Group B streptococcus is the most common (bedford-russell & plumb, 2006)
• 60% is early onset
• 20% fatal (when there is septicemia)
• Other types –listeria and herpes
• Aspiration of infected liquor in prolonged labor following early rupture of membrane
which may lead to neonatal aspiration pneumonia.
• Infection may occur due to related vaginal examination by the delivery assistant
especially when the membrane is ruptured.
• Infected birth passage may infect eyes & mouth of the neonate leading to opthalmia
neonatrum & oral thrush.
• Improper aseptic technique during care of umbilical cord may cause umbilical sepsis.

7. POSTNATAL PERIOD:
• Transmission of infection from human contact or care-givers especially
from infected hands of mother or family members & health care
providers.
• Cross infection from other baby who is infected & no barrier nursing is
practiced & universal precautions are not followed.
• Infected articles for baby care & contaminated clothing
• Invasive procedures without aseptic technique
• Infected environment around neonates at hospital or home.

8. CLASSIFICATION OF NEONATAL INFECTIONS
INTRA-UTERINE
INFECTIONS
PERINATAL
INFECTIONS
EARLY
NEONATAL
INFECTIONS
LATE NEONATAL
INFECTIONS
POSTNATAL
INFECTIONS

9. SIGNS OF INFECTIONS
• MATERNAL SIGNS:
• MATERNAL HISTORY& PRESENCE OF INFECTION
• CHORIO-AMNIONITIS
• FEVER
• RAISED CRP
• PROLONGED RUPTURE OF MEMBRANES (PROM)
• FETAL DISTRESS
• FOUL / CLOUDY LIQUOR

10. CONTD…
• FETAL SIGNS:
• PRIOR TO DELIVERY.
• SUSTAINED FETAL TACHYCARDIA >
160 BPM
• PRETERM DELIVERY –COMMON
CAUSE IS INFECTION
• LBW
• LOW APGAR (<5 AT 1 MINUTE)
• NEONATAL SIGNS:
• RESPIRATORY
• TACHYPNOEA
• APNOEA
• HYPOXIA
• NASAL FLARING
• GRUNTING
• IRREGULAR RESPIRATIONS

11. CONTD…
• CARDIOVASCULAR
• HYPOTENSION
• METABOLIC ACIDOSIS
• TACHYCARDIA
• TEMPERATURE INSTABILITY
• NEWBORN TEMPERATURE <36 OR PYREXIAL
• GASTROINTESTINAL
• VOMITING, DIARRHOEA, ABDOMINAL DISTENSION, POOR FEEDING

12. CONTD…
• NEUROLOGICAL
• ACTIVITY DECREASED OR LETHARGY, IRRITABILITY
• TREMOR OR SEIZURE, HYPOREFLEXIA OR HYPOTONIA
• HIGH PITCHED CRY, FONTANELLE FULL
• SKIN
• PALLOR OR SKIN MOTTLING
• PETECHIAE OR PURPURA
• COLD OR CLAMMY SKIN
• CYANOSIS
• JAUNDICE

13. MANAGEMENT
• Observe for signs and risks
• ‘Universal precautions’-prevention
• Minimise risk of infection
• Septic screen if infection suspected – full or partial
• Treat with antibiotics if required based on cultures
• The baby should be isolated to prevent cross infection.

14. LOCALIZED INFECTIONS
• An infections is a certain part of the baby’s body(cord,skin,eye,mouth)
• Can spread quickly through the newborn’s small body & causes sepsis.
• Quick & correct treatment of localized infections may prevent sepsis & possible
deaths.
• UMBILICAL CORD INFECTION
• Infection around the umbilical cord.
• Can easily pass through the cord- sepsis or death if treatment delayed
• Treatment- wash the cord & stump & apply gentian violet 0.5%, ampicillin &
gentamycin.

15. CONTD…
• SKIN INFECTION
• Skin pastules
• Localized or serious skin infection
• Wash the skin & apply gentian violet 0.5%, serious infection- Cloxacillin 50 mg/kg IM
• EYE INFECTION
• Bacteria- Chlamydia
• Treatment- Ceftriaxone 50 mg/kg
• ORAL THRUSH
• White patches on the mucus membrane or tongue
• Treatment- nystatin 1,00,000 U/ml- 1 to 2 ml in baby’s mouth 4 times a day, gentian
violet.

16. NEONATAL SEPSIS
• DEFINITION
• Neonatal sepsis is a clinical syndrome characterized by signs and symptoms of
infection with or without accompanying bacteremia in the first month of life. It
encompasses various systemic infections of the newborn such as septicemia,
meningitis, pneumonia, arthritis, osteomyelitis, and urinary tract infections.
• Superficial infections like conjunctivitis and oral thrush are not usually included
under neonatal sepsis.

17. CLASSIFICATION
• Early onset sepsis (EOS):
• It presents within the first 72 hours of life. In severe cases, the neonate may be
symptomatic at birth. Infants with EOS usually present with respiratory distress and
pneumonia. The source of infection is generally the maternal genital tract. Some
maternal/ perinatal conditions have been associated with an increased risk of EOS.
Knowledge about these potential risk factors would help in early diagnosis of sepsis.
• 1. Low birth weight (<2500 grams) or prematurity
• 2. Febrile illness in the mother with evidence of bacterial infection within 2 weeks prior
to delivery

18. CONTD…
• 3. Foul smelling and/or meconium stained liquor
• 4. Rupture of membranes >24 hours
• 5. Single unclean or > 3 sterile vaginal examination(s) during labor
• 6. Prolonged labor (sum of 1st and 2nd stage of labor > 24 hrs)
• 7. Perinatal asphyxia (APGAR score <4 at 1 minute) presence of foul smelling liquor or
three of the above mentioned risk factors warrant initiation of antibiotic treatment.
Infants with two risk factors should be investigated and then treated accordingly.

19. LATE ONSET SEPSIS (LOS):
• It usually presents after 72 hours of age. The source of infection in LOS is either
nosocomial (hospital-acquired) or community-acquired and neonates usually
present with septicemia, pneumonia or meningitis. Various factors that predispose
to an increased risk of nosocomial sepsis include low birth weight, prematurity,
admission in intensive care unit, mechanical ventilation, invasive procedures,
administration of parenteral fluids, and use of stock solutions.
• Factors that might increase the risk of community-acquired LOS include poor
hygiene, poor cord care, bottle-feeding, and pre-lacteal feeds. In contrast,
breastfeeding helps in prevention of infections.

20. CLINICAL FEATURES
• NON-SPECIFIC FEATURES:
• The earliest signs of sepsis are often subtle and nonspecific; indeed, a high index of
suspicion is needed for early diagnosis. Neonates with sepsis may present with one or
more of the following symptoms and signs:
• (a) Hypothermia or fever (former is more common in preterm low birth weight infants)
• (b) Lethargy, poor cry, refusal to suck
• (c) Poor perfusion, prolonged capillary refill time
• (d) Hypotonia, absent neonatal reflexes
• (e) Brady/tachycardia
• (f) Respiratory distress, apnea and gasping respiration
• (g) Hypo/hyperglycemia

21. CONTD…
• SPECIFIC FEATURES RELATED TO VARIOUS SYSTEMS:
• CENTRAL NERVOUS SYSTEM (CNS):
• Bulging Anterior Fontanelle, Vacant Stare, High-pitched Cry, Excess Irritability, Stupor/Coma,
Seizures, Neck Retraction.
• CARDIAC: Hypotension, Poor Perfusion, Shock
• GASTROINTESTINAL:
• Feed Intolerance, Vomiting, Diarrhea, Abdominal Distension, Paralytic Ileus, Necrotizing
Enterocolitis
• HEPATIC: Hepatomegaly, Direct Hyperbilirubinemia (Especially With Urinary Tract Infections)
• RENAL: Acute Renal Failure
• HEMATOLOGICAL: Bleeding, Petechiae, Purpura
• SKIN CHANGES: Multiple Pustules, Abscess, Mottling, Umbilical Redness And Discharge.

22. MANAGEMENT
• INDICATIONS FOR STARTING ANTIBIOTICS:
• The indications for starting antibiotics in neonates at risk of EOS include any one of
the following:
• (a) presence of >3 risk factors for early onset sepsis
• (b) presence of foul smelling liquor
• (c) presence of 2 antenatal risk factor(s) and a positive septic screen and strong
clinical suspicion of sepsis.
• THE INDICATIONS FOR STARTING ANTIBIOTICS IN LOS INCLUDE:
• (A) positive septic screen and/or (b) strong clinical suspicion of sepsis.

23. CONTD…
• PROPHYLACTIC ANTIBIOTICS:
• Do not use prophylactic antibiotics in the following circumstances: infants on IV fluids/TPN,
meconium aspiration syndrome, and after exchange transfusion(s). An exchange transfusion
conducted under strict asepsis (single use catheter, sterile gloves, removal of catheter after the
procedure) does not increase the risk of sepsis and hence does not merit antibiotics. However a
messy exchange transfusion could be treated with prophylactic antibiotics. In our unit, ventilated
neonates are treated with prophylactic amikacin for the period of ventilation.
• For infections that are acquired during hospital stay, resistant pathogens are likely and a
combination of ampicillin or cloxacillin with gentamicin or amikacin may be instituted. In
presence of multiple resistant strains of klebsiella and other gram-negative bacilli, a combination
of a third generation cephalosporin (cefotaxime or ceftazidime) with amikacin may be
appropriate.
• A combination of piperacillin-tazobactam with amikacin should be considered if pseudomonas
sepsis is suspected. Penicillin resistant staphylococcus aureus should be treated with cloxacillin,
nafcillin or methicillin.

24. CONTD…
• ADJUVANT THERAPY:
• EXCHANGE TRANSFUSION (ET):
• Sadana et al17 have evaluated the role of double volume exchange transfusion in septic
neonates with sclerema and demonstrated a 50% reduction in sepsis related mortality in
the treated group. We perform double-volume exchange transfusion with crossmatched
fresh whole blood as adjunctive therapy in septic neonates with sclerema.
• INTRAVENOUS IMMUNOGLOBULIN (IVIG):
• Non-specific pooled IVIG has not been found to be useful.

25. OPTHALMIA NEONATRUM
• INTRODUCTION
• Ophthalmia neonatorum refers to any conjunctivitis occurring in the first 28 days of life.
It is most commonly infective in origin: bacterial causes include chlamydia trachomatis,
neisseria gonorrhoeae, staphylococcus aureus, streptococcus pneumoniae and various
other organisms. Less often there can be viral causes - notably the herpes simplex virus.
It may also occur as a reaction to chemical irritants, and is a self-limiting condition
lasting no more than 24 to 36 hours but infections need treatment.
• In most cases ophthalmia neonatorum is a mild illness. The exception is that due to
gonococcal infection, which can progress rapidly to corneal damage and permanent
visual impairment.This may also cause systemic complications.

26. TYPES
• CHEMICAL CONJUNCTIVITIS
• There is a mild irritation, tearing and redness in a baby who has been administered
prophylactic silver nitrate (used for the prevention of gonorrhoeal infection) within the
preceding 24-48 hours.
• BACTERIAL CONJUNCTIVITIS
• This usually (but not invariably) has a longer incubation period than for the other
infective causes, presenting with a subacute onset between the 4th and 28th day of
life. Depending on the pathogen, there may be a mixed picture of a red eye with lid
swelling and a varying amount of purulent discharge. Specific common types of
bacterial infection are:
• GONORRHOEAL INFECTION - Typically, 1-5 days after birth but it may occur later:
hyperacute conjunctival injection and chemosis, lid oedema and severe purulent
discharge. There may be associated corneal ulceration and perforation.

27. CONTD…
• CHLAMYDIAL INFECTION - 5-14 days after birth (some report up to 28 days after
birth): unilateral/bilateral watery discharge which becomes copious and purulent later
on. There may be associated pre-septal cellulitis and, less commonly, rhinitis, otitis and
pneumonitis. The eyes are usually less inflamed than in the case of gonococcal
infection.
• VIRAL CONJUNCTIVITIS
• Onset is acute, 1-14 days after birth: unilateral/bilateral sero-sanguinous discharge ±
vesicular skin lesions. Other ocular features may include keratitis, anterior uveitis,
cataract, retinitis and (rarely) optic neuritis. Uncommonly, systemic infection can cause
jaundice, hepatosplenomegaly, pneumonitis, meningoencephalitis and disseminated
intravascular coagulation.

28. DIFFERENTIAL DIAGNOSIS
• A blocked nasolacrimal duct is common and results in a thick (sometimes
copious) discharge which may be sticky or crusty. The eye is not red and the
baby is otherwise well. The discharge may be intermittent and responds well
to simple cleansing. Most babies' ducts clear as they grow, the majority
functioning normally by 12 months of age.

29. MANAGEMENT
• REFERRAL
• The majority of neonates presenting with a sticky discharge have a benign cause - most
frequently due to blocked nasolacrimal duct(s). Features suggesting that referral is
necessary are those suggestive of gonococcal involvement, and include:
• Conjunctival redness, especially if the bulbar conjunctiva (overlying the sclera) is
involved. If the onset is sudden and severe. If the baby is distressed or unwell. If both
eyes are affected. If maternal gonococcal infection is suspected. If the mother is
concerned, or you are concerned.
• If you suspect gonococcal infection, refer immediately. Early and appropriate treatment
have long been recognised as the key to preventing consequent blindness.

30. CONTD…
• INITIAL THERAPY
• Prior to results from gram staining (or if these are inconclusive), it is appropriate to
start the infant on a broad-spectrum antibiotic - eg, ofloxacin 0.3% QDS for a week, or
until the microbiological results have come back.
• If the initial infection recurs, chlamydia should be reconsidered (even if the baby first
tested negative), as this organism is difficult to demonstrate in the laboratory and can
be missed.
• Chemical conjunctivitis: no treatment is required.These babies need early review (24
hours) to confirm that this was indeed a case of chemical irritation as opposed to early
infection.
• Bacterial infection : treatment should be guided by the organism grown. If there is
corneal involvement, the baby may be hospitalised and treated as for microbial
keratitis.

31. CONTD…
• Chlamydial infection: oral erythromycin syrup (50 mg/kg/day in
four divided doses) for 14 days. Topical treatment alone is not
sufficient (and is not usually felt to be necessary when systemic
treatment is taken). The presence of chlamydia in the eyes
invariably indicates its presence in the respiratory tract too, which
is a further reason for systemic therapy.

32. CONTD…
• The mother and her sexual partner(s) will also need treating Gonorrhoeal infection.
These babies need hospitalisation and evaluation for disseminated disease.
• Hourly saline lavage is recommended to remove the discharge (qds). Additionally,
these infants can be treated with bacitracin eye ointment 2- to 4-hourly (topical
penicillins are unreliable due to resistance). If penicillin sensitivity is established then
penicillin drops are also used.
• There is no established treatment protocol but options include ceftriaxone (single
dose: 25-50 mg/kg intravenously (IV) or intramuscularly (IM), no more than 125 mg in
total) or cefotaxime (single dose: 100 mg/kg IV or IM).
• Topical atropine is used for corneal involvement.

33. CONTD…
• VIRAL INFECTION : These babies should be hospitalised and treated with IV aciclovir
(full-term infants: 45-60 mg/kg/day in three doses. This is continued for 14 days if there
is limited disease and 21 days if there is disseminated disease, which can be devastating)
in addition to topical antiviral preparations. Complications the complications mainly
relate to gonococcal conjunctivitis. Most other causes of conjunctivitis in the newborn
are fairly benign.
• GONOCOCCAL COMPLICATIONS INCLUDE:
• Keratitis. Conjunctival scarring. Superior corneal pannus.
• SIDE-EFFECTS OF TREATMENT (RARELY), Such as the association between oral
erythromycin and infantile hypertrophic pyloric stenosis (IHPS) reported in infants aged
<6 weeks, permanent visual impairment.

34. PROGNOSIS
• CHLAMYDIAL INFECTION: Good - 80% fully recover after one course of
treatment.
• BACTERIAL INFECTION: Rarely fails to respond to appropriate treatment.
• VIRAL INFECTION: The ocular prognosis can be poor and the systemic
sequelae may be fatal.
• CHEMICAL IRRITATION: Good - full spontaneous recovery expected after
24-36 hours.

35. NURSING MANAGEMENT
• All infants should receive ocular prophylaxis at birth to prevent gonococcal opthalmia.
Neonates presenting with signs of conjunctivitis should have conjunctival swab to be
sent.
• Infants should be followed during their treatment & upon completion of therapy to
ensure resolution of symptoms. For cases in which sexually transmitted bacteria are
implicated, the mothers & their sexual partners should be treated.
• Five clean practices should be followed during delivery- clean hands, clean tie, clean
blade, clean cord stump. Another important aspect is clean clothing for mother & baby.
• Hand washing before & after handling of the babies.
• Maintenance of cleanliness of the environment – delivery room, neonatal care unit,
postnatal area etc.

36. JOURNAL ARTICLE
• “RISK FACTORS FOR NEONATAL SEPSIS IN PUBLIC HOSPITALS OF MEKELLE CITY,
NORTH ETHIOPIA, 2015:UNMATCHED CASE CONTROL STUDY”
-DESTAALEM GEBREMEDHIN ,HAFTUBERHE
• OBJECTIVES
• Neonatal sepsis is a leading cause of neonatal morbidity and mortality, particularly in
the developing countries. Delays in the identification and treatment of neonatal sepsis
are among the main contributors to the high mortality. The aim of this study was to
determine the risk factors of neonatal sepsis in public hospitals of mekelle
city,tigrayregion,north ethiopia,2015.

37. CONTD…
• METHODS
• A hospital based case control study was done in public hospitals of mekelle city,
tigray region. Cases were neonates who had sepsis with their index mothers and
controls were neonates who hadn’t had sepsis with their index mothers.
Hematologic findings were used to diagnose sepsis once the neonates were being
clinically suspected. Cases and controls were selected using the systematic
sampling technique. Data were entered using epi info version 7 and the analyze
SPSS window20.The binary logistic regression model was used to test the
association between dependent an independent variables and multivariable
logistic regression was used to identify the associated risk factors to neonatal
sepsis.

38. CONTD..
• FINDINGS
• A total of 78 cases and 156 controls were included in this study. More than three
quarters (76.8%)of cases had early onset sepsis. The multivariable logistic regression
analysis showed that the possible risk factors of neonatal sepsis in this study were;
history of maternal urinary tract infection or sexually transmitted infection
[AOR=5.23;95% CI (1.82, 15.04)], prolonged rupture of membrane [AOR=7.43;95% CI
(2.04,27.1)], place of delivery; health center delivery[AOR=5.7;95% CI(1.71,19.03)],
intrapartum fever[AOR=6.1 95% CI(1.29,28.31)], APGAR score<7 at 5th
minute[AOR=68.9;95% CI(3.63,1308)] and not crying immediately at
birth[AOR=124.0;95% CI(6.5,2379)].