neonatal sepsis and neonatal meningitis

1. Neonatal Sepsis
Dr. Tharindu Nayanagith Gunasiri
House Officer - Paediatrics

2. Neonatal sepsis
 In Sri Lanka 20% of neonatal
mortality is due to Neonatal Sepsis
!!!

3. What is Neonatal Sepsis ?
 Clinical syndrome
 Signs and symptoms of infection
 With or without accompanying bacteremia
 In 1st month of life

4. Consists of systemic infections
 Septicemia
 Meningitis
 Pneumonia
 Urinary tract infections
 Necrotizing enterocolitis
 Arthritis & osteomyelitis

5. Early onset sepsis (EOS):
 Presents within the first 72 hours of life
 The source of infection is generally the maternal
genital tract.
(GBS, E. coli, Listeria monocytogenes)
 Commonly manifest as respiratory distress due to
congenital pneumonia

6. Late onset sepsis (LOS):
 It usually presents after 72 hours
of age.
 The source of infection in LOS
 nosocomial (hospital-acquired)
 community-acquired
 ( Klebsiella, E. coli,
Pseudomonas, Staphylococcus
aureus, coagulase negative
staphylococcus )

7. Risk factors for early onset sepsis
1.Low birth weight (<2500 grams) prematurity
2. Maternal pyrexia
3. Foul smelling liquor- Chorioamnitis
4. Rupture of membranes >18 hours.
5. Repeated vaginal examination(s) during labor
6. Prolonged labour ( labour > 24 hrs)
7. Perinatal asphyxia

8. Risk Factors for nosocomial sepsis
 Low birth weight
 Prematurity
 Admission in intensive care unit
 Mechanical ventilation
 Invasive procedures – Intubation, UVC insertion
 Administration of parenteral fluids

9. Factors that increase the risk of
community acquired LOS
 Poor hygiene
 Lack of breastfeeding
 Poor cord care
 Bottle-feeding

10. Identification of Sepsis
The earliest signs of sepsis
 subtle
 nonspecific
High index of suspicion is needed for
early diagnosis.

11. Identification of Sepsis
 fever or hypothermia
 lethargy or irritability
 poor cry
 refusal to suck
 hypotonia
 convulsions- in meningitis
 bulging fontanels (late sign)

12. Identification of Sepsis
 Jaundice
 hypolycemia
 poor perfusion, prolonged capillary refill time (CRFT)
 brady / tachycardia
 respiratory distress
 apnea and gasping respiration
 metabolic acidosis.

13. Septic Screen
Investigations to identify the focus of infection &
the causative organism
 Full Sepsis Screen
 Partial sepsis screen

14. Septic screen
 Blood Cultures
 FBC - Total leukocyte count absolute neutrophil
count , immature to total neutrophil ratio
 C reactive protein CRP
 Urine culture
 Chest Xray
 LP

15. Blood culture
It is the gold standard for diagnosis of
septicemia
 Should be performed in all cases of suspected sepsis
prior to starting antibiotics.
 A positive blood culture with sensitivity of the
isolated organism is the best guide to antimicrobial
therapy.
 Therefore it is very important to follow the proper
procedure for collecting a blood culture.

16. If sepsis is suspected antibiotics
should be commenced as early as
possible after relevant cultures !!!
 Ensure correct dosage !!!

17. Other investigations
 Serum bilirubin – if jaundiced
 Serum electrolytes
 Blood sugar

18. Causative Organisms
Group B Streptococcus (GBS)
Gram negatives –E. coli, Klebsiella, Proteus
 Pseudomonas
Gram positive - Staph. aureus
Listeria monocytogenes

19. Parenteral antibiotics in neonatal
sepsis
EOS Septicemia
 IV Benzyl Penicillin + Gentamicin 7-10 days (if
cultures positive )
Meningitis
 IV Benzyl Penicillin !4 days
 IV Cefotaxime 21 days
Late onset if staph is suspected use
 IV Cloxacillin + IV Cefotaxime

20. 3rd Line antibiotics
 Meropenem +/- Vancomycin
 Consider including Vancomycin if Staph/MRSA
is suspected + use of central lines.
 Starting with clinical judgement and
adjusted according to culture reports +
clinical response

21. Duration of Antibiotic therapy
 Septicaemia 7- 10 days
 Meningitis 21 days ( if GBS- 14 days)
 Bone & joint 4 – 6 wks

22. Duration of Antibiotic therapy
 Prophylaxis (asymptomatic baby) ???
 Blood culture +ve with normal CSF ???
 Initially symptomatic baby but
screening –ve and clinically well ???
 Symptomatic baby, respond to Rx
within 48h with FBC/CRP +ve but
Blood culture –ve ???
 IF INITIAL CRP HIGH BEST TO TREAT
UNTIL LEVELS BECOME NORMAL !!!

23. Complications in severe sepsis
 Gastrointestinal: vomiting, blood stained stools ,
abdominal distension
Necrotizing Enterocolitis (NEC).
 Cardiac: Hypotension, poor perfusion, shock.
 Renal: Acute renal failure.
 Hematological: DIC -Bleeding, petechiae, purpura.

24. What are the superficial
infections of a newborn ?
 Skin pustules
 Eye discharge – conjunctivitis
 Umbilical stump infection
 Usually caused by staphylococcus aureus

25. Prevention of neonatal sepsis
 Identify at risk babies
 Minimum vaginal examination during labour
 Proper identification and treatment of chorioamnionitis
 Cord care
 Hand hygiene
 Maintain sterility in postnatal ward and neonatal units

26. Neonatal Meningitis
 Neonatal meningitis is the inflammation
of the meninges during the first 28 days
of life.
Etiology
Bacterial Viral Fungal

27. NEONATAL MENINGITIS
 Suspected bacterial meningitis is a Medical
EMERGENCY !!!
 If untreated invariably fatal.
 Even with treatment high morbidity and
mortality.
 Few hours delay can have huge difference in
final outcome.
 Lasting consequences.

28. Clinical features
 Not all patients have Fever, Neck Stiffness and Altered
Mental Status.
 Lethargy 50%
 Fever/Hypothermia 61%
 Preceding URTI +/- Respiratory distress
 Convulsions 40%
 Irritability 32%
 Bulging AF 28%
 Jaundice 28%
 Apnea 7%

30. Investigations
 FBC
 CRP
 ESR
 Blood Culture
 Lumber Puncture (Blood sugar prior to LP)
 USS brain/CT
 EEG

31. Lumbar puncture (LP)
INDICATIONS
 All suspected meningitis
 All suspected late onset septicemia
 All culture positive sepsis
 Severe sepsis EOS/LOS
 Early onset RDS with signs and
symptoms of sepsis
 Lumbar puncture could be
postponed in a critically sick
neonates- perform an interval
lumber puncture when the baby is
stable

32. CSF interpretation
 Cell count – up-to 20 cells may be normal if
predominately lymphocytes .
But if more neutrophils – with other clinical features
– consider positive
 CSF proteins- up-to 100 mg may be normal in
preterm may be even 150- 200 mg may be normal
 CSF sugar less than 2/3 rd of blood sugar
 CSF antigen
 CSF Culture

34. MANAGEMENT
Initial stabilization – Airway, Breathing, Circulation
Fluid management
Maintain blood sugar levels
Seizure control
Antibiotics-
•Minimum 14 days for GBS
•21 days for Gram Negative
•May need longer duration if complications arise

36. Complications of neonatal meningitis
Acute
 subdural effusion
 septic shock
 cranial nerve palsies
 hydrocephalus
 inappropriate ADH secretion
 Cerebral abscess
Long term
 cerebral palsy
 developmental delay
 deafness
 epilepsy

37. Questions?

38. References
 Standard treatment protocols in pediatrics and
neonatology 2017
 Nelson textbook of Pediatrics
 National Guidelines for Newborn care – Volume 2
 Guidelines for management of CNS infections

39. Thank you