Neonatal infections

THIS SLIDE INCLUDES THE MANAGEMENT AND PREVENTION OF NEONATAL INFECTIONS. IF ANY SUGGESTION GIVE IT IN COMMENT BOX.

1. SEMINAR ON NEONATAL INFECTION, PREVENTION AND MANAGEMENT BY, MR. ABHIJIT BHOYAR M. SC. NURSING CHILD HEALTH

2. GENERAL OBJECTIVES – At the end of the topic the student will be able to gain the knowledge about the neonatal infections and able to do the care of neonate in the hospital.

3. SPECIFIC OBJECTIVES – At the end of the seminar the student will be able to. Define the neonatal infections. Enlist the etiological factors of the neonatal infection. Enlist the some common neonatal infection

4. Discuss about the common infections and there management. Discuss about the prevention of neonatal infection.

5. INTRODUCTION Neonatal infection is the clinical syndrome of multiplying bacteria in the blood with systemic signs and symptoms of inflammation. Newborn infants are at a higher risk of contracting various infections. Prenatal infections, especially neonatal bacterial infection is the commonest cause of neonatal mortality in India

6. Infection can occur in intrauterine life or during delivery or in the neonatal period. The neonates are more susceptible to infection because they lack in natural immunity and take some time for the development of acquired immunity.

7. DEFINITION Neonatal infection is systematic bacterial which incorporates septicemia, pneumonia & meningitis of newborn.

8. INCIDENCE Black infants have an increased incidence of GBS disease and late-onset sepsis. This is observed even after the risk factors of low birth weight and decreased maternal age have been controlled for.

9. In all races, the incidence of bacterial sepsis and meningitis, especially with gram-negative enteric bacilli, is higher in males than in females Premature infants have an increased incidence of sepsis.

10. The incidence of sepsis is significantly higher in infants with a birth weight of less than 1000 g (26 per 1000 live births) than in infants with a birth weight of 1000-2000 g (8-9 per 1000 live births). The risk of death or meningitis from sepsis is higher in infants with low birth weight than in full-term neonates.

11. ETIOLOGY Antenatal period Intrauterine infection Ascending infection with contaminated liquor amnii and amnionitis related to infected birth passage and premature rupture of membrane

12. Intranatal period Aspiration of infected liquor repeated vaginal examination Infected birth passage Improper aseptic techniques

13. Postnatal period human contact or care givers Cross infection from other babies Infected article Invasive procedure Infected environment

14. Risk factors Maternal GBS colonization (especially if untreated during labor) Premature rupture of membranes (PROM) Preterm rupture of membranes Prolonged rupture of membranes Prematurity Maternal urinary tract infection Chorioamnionitis  

15. OTHER FACTORS Congenital anomalies Meconium staining Low Apgar score Maternal fever Maternal UTI Poor prenatal care Low socioeconomic status History of recurrent abortion Birth asphyxia Low birth weight Maternal substance abuse Difficult delivery

16. COMMON INFECTION IN NEONATE   SUPERFICIAL Eyes, Skin, Umbilicus, And Oral Cavity. LOCALIZED OR SYSTEMIC septicemia , DIC(disseminated intravascular coagulopathy ), pyelonephritis

17. The presence of three of the following feature should make alert to the possibility of intrauterine infections Maternal history of infection Intrauterine growth retardation Hepatosplenomegaly Jaundice Petechie and purpura Meningo -encephalitis(with microcephaly , hydrocephaly, cerebral calcification, cataract) Osteochondritis Raised IgM in cord blood.

18. NEONATAL CONJUNCTIVITIS ( ophthalmia neonatorum ) DEFINITION -Inflammation of conjunctiva during first three week of life is term as ophthalmia neonatorum . Sticky eyes without purulent discharge are common during first 2 to 3 days after birth Unilateral conjunctivitis after 5 days (Chlamydia trachomotis )

19. Purulent discharge (gonococcus ) affect one or both eyes within 48 hours of age. Other microorganism causing neonatal conjunctivitis are streptococcus , staphylococcus, pnenmonia , E. coli, herpix simplex virus, etc chemical conjunctivitis may occure due to irritation of silver nitrate , soap and local antibiotic drops.

20. Mode of infection Infected hands of caregiver, Infected birth canal and Cross infection from other baby. Infection can occurs directly from other sites of infection like skin and umbilicus.

21. Clinical features White sticky eyes with or without discharge ranging from watery or purulent or mucopurulent in one or both eyes. The eyelid may be markedly swollen and stuck together with redness of eyes. Closed eyelid may present due to spasm of ocular muscle.

22. Management Antibiotic therapy (as eye drop or in parenteral route The baby should be kept isolated to prevent cross infection. Sulfacitamide or framacetin or chloramphinicol drops or erythromycin ointment can be used

23. For gonococol infection penicillin therapy should be initiated If organism are resistance to penicillin, then cefotaxim or ceftraxone are used.

24. Cleaning of the infected eyes with sterile cotton swabs soaked in saline should be done after hand washing Instillation of eye drops to be done with proper aseptic technique.

25. Preventive management Treatment of maternal infection, Aseptic techniques during delivery , Special care and attention in face and breech presentation, Isolation of the infected baby Maintenance of general cleanliness.

26. Prognosis Prognosis is good if detected and treated promptly In neglected cases, orbital cellulitis and dacrocystic with obstruction of nasolacrimal duct may develop.

27. In gonococcus infection, corneal ulceration may occur leading to cornial opacity. In rare cases blindness may occur if no treatment done.

28. UMBILICAL SEPSIS ( omphalitis ) The incidence of umbilical sepsis is reduced due to aseptic technique and clean practices at birth.

29. source of infection Unhygienic environment of delivery., Umbilical catheterization, Exchange transfusion, Contaminated cord cutting instrument, Infected hands of caregiver or infected clothing

30. The causative organisms are mainly staphylococcus, E. coli, or any pyogenic organisms. Clostridium tetani can also infect umbilical cord and produces tetanus neonatorum .

31. The incidence of tetanus neonatorum is also reduced due to administration of tetanus toxoid to antenatal mothers. But till it is found in the rural area in home delivery and delivery in very unhygienic condition.

32. Clinical features Swollen and moist periumbilical tissue with redness, Foul smelling and serous and seropurulent discharge,

33. ` Delayed falling off umbilical cord and fever. Jaundice and features of septicemia may appear in complicated cases. The clinical features of tetanus are found in clostridium tetani infections.

34. Management Management of this condition is done with dressing or the infected cord with triple dye or sprit or antibiotic powder or lotion. Umbilical cord should leave uncovered rather than application of dressing..

35. Antibiotic The infected babies should be kept in the isolation. Culture and sensitivity test of umbilical swab may be needed in some cases who are not responding to the routine treatment

36. Umbilical sepsis can be complicated with thrombophlebitis of umbilical veins, umbilical granuloma , hepatitis, liver abscess, peritonitis and portal hypertension

37. Prognosis Prognosis depends upon the nature of infection, initiation of management and nursing care. Prevention of umbilical infection is more easy and important in life of neonates.

38. ORAL THRUSH It is fungal infection of the oral cavity and tongue by Candida albicans in the late first week or second week of age. Infection occur from infected birth canal,

39. Infected feeding bottles and Teats or contaminated feeding articles, mothers hands and breast nipples. It may develop due to prolonged antibiotic therapy.

40. Clinical manifestation Milky-white elevated patches on the buccal mucosa, lips, tongue and gums, which cannot be easily wiped off with gauze and oozes blood on attempt to scrap the patches.

41. Swallowing difficulties may present due to posterior oropharengeal white patches. Sucking reflex may be normal. infection may cause monilial diarrhea, Perineal moniliasis and lung infection.

42. Management Oral application 0.5 percent aqueous solution of gentian violet after each feed. Nystatin and ketokonazol or cotrimazole lotions ; 4 times per day for 5 to 7 days. Parenteral antifungal drugs can be administered in disseminated candidiasis .

43. Prevention This condition can be prevented by the treatment of maternal fungal infection, adequate cleaning of the utensils and maintenances of general cleanliness and hygienic measures.

44. PYODERMA Superficial skin infection (staphylococcus aureus ). The skin eruptions and pastules are commonly seen on scalp, neck, groin and axillae . These are more commonly found in summer month.

45. This infection occurs from contaminated hands of the personnel responsible for care of the neonate. Unhygienic environment, spread from other infected baby and contaminated baby clothing can also result in this infections.

46. Clinical manifestation The infection may spread to cause abscess, osteomyelitis , parotitis and septicemia, The life threatening staphylococcal infection may result in pemphigus neonatorum that is manifested as marked erythemia , bullas lesion and exfoliation which gives appearance of scaled skin syndrome.

47. Management Treatment of these lesions includes puncturing, cleaning with hexachlorophene, Antiseptic skin care and application of triple dye over the punctured lesions. Pus should be sent for culture and sensitivity test..

48. In case of spread infection, erythromycin 50 mg/kg per day per orally in 3 divided doses In complicated cases, parenteral administration of antibiotic should be done. The baby to be kept in the isolation

49. Prevention This condition can be prevented by avoidance of dip baby bath in hospital delivery and during hospital stay, isolation of infected baby, maintenances of general cleanliness (including clean clothing ) and treatment of source of infection.

50. Prognosis Prognosis is usually good if treated promptly and good nursing care is provided.

51. TETANUS NEONATORUM Till recently tetanus neonatorum accounted for the 6.5 percent of deaths in India. Every year nearly 230-280 thousands neonates used to die within first month of life due to neonatal tetanus.

52. The disease is caused by infection of umbilical stump by clostridium tetani . Contamination of infectioin of the umbilical stumps at the time of cutting the cord is an important cause. The condition is limited to domociliary midwifery, as untrained dais use unclene sharp weapons to cut the umbilical cord.

53. They even paint the stump with cowdung with the mistaken belief of its purifying properties. Lack of active immunization of adult population with tetanus toxoid also contributes to the high incidence of this highly fatal though entirely preventable disease.

54. Clinical features Common age of onset of symptoms is 5-15 days Excessive unexplained crying, follow by refusal of feed and apathy The infant keeps the mouth slightly opened to pull as a result of spasm of the muscle of the neck but reflex mouth during feeds

55. Reflex spasm of pharyngeal muscle lead to dysphagia and chocking during feeds. During handling and touching, lock-jaw or trismus is follow by spasm of the limbs. The usual flexed posture of the baby is replaced by generalized rigidity and opisthotonus in extension.

56. The spasm of larynx and respiratory muscles is associated with apnea and cyanosis. The spasms are characteristically induced by stimuli of touch, noise and bright light. Frequently muscular spasm lead to fever, tachycardia and Tachypnea .

57. Management Active immunization of the pregnant women against the tetanus Public health education regarding the need for asepsis while cutting the umbilical cord, have effectively reduced the incidence of tetanus neonatorum .

58. General measures The infant should be nursed in a quite room. Handling should be reduced Intramuscular injections must be avoided, Temperature should be watched and controlled. Oral secretion should be suck periodically.

59. Intravenous infusion Oral feeding should be stopped Intravenous line should be established, Provide adequate fluids, calories, and electrolytes, it offers a convenient route for administration of various drugs. After two to three days, milk feeding through nosogastric tube may be started.

60. Antitoxin serum Human tetanus specific immunoglobulin in single dose of 250 i . u./kg intravenously generally sufficient higher doses have not shown to be of any additional benefits.

61. The use of intrathecal antitetanus serum (250 units of human tetanus specific immunoglobulin)appear to conform additional therapeutic benefit by bathing and traveling along the nerve roots to inactivate the toxins. It is not associated with the any serious side effects.

62. Sedation Diazepam 2 to 5 mg (maximum of 2 mg/kg per dose) Chlorpromazine 2mg/kg/dose should be administered slowly intravenously every 2 to 4 hours, altering with each other , so that a sedative dose is being given every1 to 2 hours. Phenobarbitone should preferably be avoided during diazepam therapy to safeguard against apnea attacks.

63. Muscle relaxants Methacarbanol (50-75 mg/kg/day iv in 2 divided doses) Mephenesin (30-120 mg/kg/dose every one hourly orally) Antibiotics penicillin, gentamicin or amicasin cefotaxim should be given intravenously.

64. Tracheostomy or assisted ventilation Early resort to assisted ventilation along with muscle relaxants has significaltly improved the outlook in tetanus neonaterum . It is indicated that whenever the infant gets frequent episodes of laryngeal spasm. Apneic attack with cyanosis or central respiratory failure.

65. Prognosis The overall mortality rate varies from 50- 75 % but those who servieves do not manifest any mental sequallae except when apneic episodes are unduly prolong and unattended.

66. NEONATAL SEPSIS Definition The systemic bacterial infections of neonates are termed as neonatal sepsis which incorporates septicemia, pneumonia and meningitis of the newborn.

67. Etiological factors klebsiella pneumonia, staphylococcus aureus , E. coli, pseudomonas aeruginosa

68. Predisposing factor Intrauterine Infections, Premature Rupture Of Membrane, Muconium Stained Liquor, Repeated Vaginal Examination, Maternal Infections, Lack Of Aseptic Practices, Birth asphyxia, Resuscitation without aseptic precaution, Low birth weight, Invasive procedure , Needle pricks, Superficial infections, Aspiration of feed and lack of breast feeding.

69. sources of infection Infusion sets, IV sites, Face masks, feeding bottles, Catheters, ventilators, Resuscitators, incubators, Baby care contaminated articles, Infected care givers and unhygienic environments.

70. TYPES EARLY ONSET SEPSIS In The First 48 Hours After Birth Associated with acquisition of microorganisms from the mother. Trans-placental infection or an ascending infection from the cervix LATE ONSET SEPSIS After 48 hours of age acquired from the care giving environment. It acquired as nosocomial infection from baby care area or due to,inappropriate neonatal care.

71. Clinical manifestation Early onset neonatal sepsis may present as perinatal hypoxia, resuscitation difficulties and congenital pneumonia in the form of respiratory distress. The late onset neonatal sepsis in a very small baby may be silent who may die suddenly without presenting any signs and symptoms.

72. lethargic, inactive, pale or unresponsive and refuses to suck. Hypothermia is common than fever, in neonatal sepsis. Poor cry, vacant look, comatose and not arousable baby with distension of abdomen, diarrhea, vomiting, less weight gain or loss of weight and poor neonatal reflexes. episodes of apnea or gasping may be the only feature of the condition.

73. In Sick neonate, skin may become tight giving a hide bound feel ( sclerema ) and poor perfusion are found. In critical neonate circumpolar cyanosis, shock, bleeding, excessive jaundice and renal failure may develop.

74. The evidence of pneumonia may include fast breathing. Chest retraction, grunting, early cyanosis, apneal spell in addition to inactivity and poor feeding. Cough is unusual.

75. Meningitis is often silent, the clinical features are dominated by manifestation of septicemia. But the presence of high pitched cry, fever, irritability, convolutions, twitching, blank look, neck retraction and bulging fontanel are highly suggestive of meningitis.

76. The neonatal sepsis may present with hypoglycemia, urinary tract infection, coagulopathy (DIC) , necrotizing enterocolitis (NEC) ,

77. Investigation history taking & physical examination, blood culture, swab culture from septic umbilicus or from any other location of superficial infections and lumber puncture for CSF study. Other useful investigation are urine for routine examination and culture, chest x ray , blood sugar, serum bilirubin , leucocytes count, ESR c-reactive protein, for sepsis screening procedures.

78. MANAGEMENT Cardiopulmonary support and intravenous (IV) nutrition may be required during the acute phase of the illness until the infant’s condition stabilizes. Monitoring of blood pressure, vital signs, hematocrit , platelets, and coagulation studies is vital.

79. Blood product transfusion, including packed red blood cells (PRBCs), platelets, and fresh frozen plasma (FFP), is indicated An infant with temperature instability needs thermoregulatory support with a radiant warmer or incubator. Once the infant is stable from a cardiopulmonary standpoint, parental contact is important.

80. Surgical consultation for central line If an abscess is present, surgical drainage may be necessary; IV antibiotic therapy cannot adequately penetrate an abscess, and antibiotic treatment alone is ineffective.

81. Additional therapies granulocyte transfusion, IV immune globulin ( IVIg ) infusion exchange transfusion,

82. Supportive care Maintenance of warmth Intravenous fluid should be administered Oxygen therapy should be provided Bag and mask ventilation with the oxygen therapy Vitamin k 1mg intramuscularly should be given

83. Enteral feed is avoided if the neonate is very sick or has abdominal distension Other supportive measure includes gentle physical stimulation, nasogastric aspiration, close and constant monitoring of infants condition and experts nursing care.

84. Antibiotic Therapy Ampicillin Vancomycin Chloramphenicol Oxacillin Metronidazole ( Flagyl ) Gentamicin Cefotaxime ( Claforan )

85. Antivirals Acyclovir ( Zovirax ) Zidovudine ( Retrovir ) Antifungals Fluconazole ( Diflucan ) Amphotericin B ( AmBisome )

86. SURGICAL Surgeries may done accourding to the patient condition and the diagnosis surgeries like VP shunting. PROGNOSIS Almost 25-30 % neonates die in case of neonatal sepsis. Surgical procedure adversely affect the prognosis

87. NURSING MANAGEMENT OF NEONATAL INFECTION Organism can be carried to neonates on the hands or under the nails or jewelry of caregiver, No one with a skin or other infection should enter the nursery or the rooms occupied by the mothers.

88. A mother who become infected should be isolated and, if there is any question of contamination, her neonate should be isolated from other infants in the nursery.

89. Culture are done All infants whose cultures are positive, whether ill or not, must be isolated Appropriate supportive antibiotic therapy is given to the ill infants .

90. After all neonates have been discharge from the contaminated nursery, the room and its contents must be thoroughly cleaned. Contaminated equipment should be washed and sterilized The parents should have an opportunity to share their feelings concerning the infection of their neonates

91. NURSING DIAGNOSIS OF NEONATAL INFECTION High risk for neonatal infection ineffective breathing patterns altered growth and development Altered nutrition less than body requirements Impaired skin integrity Knowledge deficit

92. PREVENTION OF NEONATAL INFECTION Strict aseptic management of institutional delivery. Five clean practices in home delivery- clean surface, clean hand, clean cord tie, clean blade and clean care stump.

93. Hand washing before and after the handling the baby. Use of sterile gown before entering the baby care unit/ neonatal nursery and changing the shoes.

94. Minimum handling the newborn baby. Exclusion of the infected persons or carriers from the neonatal care area. Maintenances of cleanliness of the environment, that is delivery room, neonatal care unit, postnatal area and separate area for mother and baby at home.

95. Use of separate and disposable belonging for each baby, e.g., clothing, feeding, equipment, etc. Aseptic cleaning of baby-cot, incubator, warmer, phototherapy machine, weighing machine , etc. Strict asepsis for all invasive procedure. Maintenance of general cleanliness of baby and mother. Teaching the mother to maintain the hygienic measures.

96. Separate accommodation of the infected baby and outside confined baby. Avoid unnecessary IV fluid infections needle pricks and no sharing of needles and syringes. Visitors to be restricted in postnatal ward. Any baby showing features, suggestive of infections should be isolated immediately.

97. Encoring exclusive breast feeding and no prelacteal feeding . Strict aseptic measures for expressed breast milk feeding or artificial feeding. Prevention and treatment of maternal infection in antenatal and postnatal period. Active immunization to the mother.

98. Prophylactic antibiotic therapy to be given, if any three of the following factor are present, considering the baby is infected ( presumed early sepsis ) and should be treated with antibiotics ( ampicillin and gentamycin ) immediately after birth . preterm baby less than 36 weeks or birth weight less than 2 kg, maternal feeding in the preceding 2 weeks, foul smelling liquor, prolong rupture of membrane more than 24 hours, e) more than three vaginal examination in labor, f) birth asphyxia, Apgar scoreless than 4 at 5 minute, g) prolonged or difficult delivery with instrumentation

99. DIATORY MANAGEMENT FOR NEONATAL INFECTION Because of gastrointestinal (GI) symptoms, feeding intolerance, or poor feeding, it may be necessary to give the neonate nothing by mouth (nil per os ; NPO) during the first days of treatment.

100. Consider parenteral nutrition to ensure that the patient’s intake of calories, protein, minerals, and electrolytes is adequate during this period. For the NEONATE whose condition is seriously compromised, feeding may be restarted via a nasogastric tube For most infants, breast milk is the enteral diet recommended.

101. CONCLUSION

102. SUMMARY

103. THANK YOU