Neonatal infections

neonatal infections.

1. IDENTIFICATION AND CLASSIFICATION OF NEONATAL INFECTIONS, OPHTHALMIA NEONATORUM, CONGENETAL SYPHILLIS AND HIV &AIDS.    

2. Presented By Ulfat amin Msc pediatric nursing

3. INTRODUCTION Infections of neonates during neonatal period are called as Neonatal infections. Neonatal infections, are the most common cause of neonatal mortality in India. Infections can occur in intrauterine life or during delivery or in neonatal period. The neonates are more susceptible to infections because they lack natural immunity and take some time for development of acquired immunity.

4. TERMINOLOGY ANTENATAL: Period between the conception to child birth. POSTNATAL: Period after birth CONJUNCTIVA: The clear mucous membrane that lines the inner surface of eye lids and the exposed surface of eye ball and sclera. CONGENITAL: Present since birth HIV: Human Immuno Virus AIDS: Acquired Immuno Deficiency Syndrome

5. DEFINITION OF NEONATAL INFECTIONS: Invasion and uncontrollable growth of pathogenic microorganisms in the body of neonate is known as neonatal infections. SOURCES OF INFECTIONS: Infections can occur in antenatal, intranatal and postnatal period due to various conditions.

6. ANTENATAL PERIOD Antenatal infections may occur due to various micro organism and described with an acronym of STORCH where in: S  syphilis T  toxoplasmosis. O  Other (Gonococci Infections , Tubercular Infections, Malaria, Varicella, Hepatitis B, HIV Etc) R  Rubella C  Cytomegalovirus And H  Herpes Simplex Virus. These infections can develop due to direct transplacental transfer or following placental infections.

7. INTRANATAL PERIOD Aspiration of infected liquor in prolonged labour 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 the eyes and mouth of the neonate leading to Opthalmia neonatorum and oral thrush. Improper aseptic technique during care of umbilical cord may cause umbilical sepsis. Ascending Infections with contaminated liquor amnii and amnionitis related to infected birth passage and premature rapture of membrane may also lead to intrauterine infections of the fetus.

8. POSTNATAL PERIOD The following are important cause of neonatal infections in postnatal period: Transmission of infection from human contact or care givers especially from infected hands of mother or family members and health care providers Cross infection from other baby who is infected and no barrier nursing is practiced and universal precautions are not followed Infected articles for baby care and contaminated clothing Invasive procedures without aseptic technique Infected environment around the neonates at hospital or home

9. PREDISPOSING FACTORS RESPONSIBLE FOR NEONATAL INFECTIONS The Predisposing Factors Of Neonatal Infections Are: Low birth weight infant. Contaminated intrauterine environment like prolonged rapture of membrane , unhygienic and multiple vaginal examination, meconium-stained liquor etc.

10. Infected birth canal and infection at birth in delivery room or neonatal care units. Birth asphyxia and resuscitations Congenital anomalies Various procedures with inadequate asepsis during iv infusion , parenteral medication, endo tracheal intubation, assisted ventilation, exchange blood transfusion etc. Artificial feeding other than human milk

11. CLASSIFICATION OF NEWBORN INFECTIONS. ON THE BASES OF SOURCE:- the various types are 1. Intrauterine infections : it refers to infection acquired in utero. The STORCH a group of infections (syphilis, toxoplasmosis, rubella, cytomegalovirus, herpes simplex virus) belonging to this category. Viral infections in utero may lead to fetal death, congenital malformations or severe systemic manifestations of disease.

12. The presence of any three of the following features should make alert to the possibility of intrauterine infections. Maternal history of infection. Intrauterine growth retardation Hepatospleenomegaly. Jaundice. Meningo-encephalitis. Raised IgM in cord blood

13. 2 . Perinatal infections : it refers to infection that is acquired just before pregnancy and during delivery from the mother. Such an infection occurs from the organisms colonizing the birth passage. 3. Early neonatal infection : should be limited to perinatal infection with manifestations occurring within 72 hours of birth.

14. 4.Late–onset neonatal infection : it is sepsis occurring after 8 th day of birth. 5.Post neonatal infection : it refers to infections occur after 28 days of delivery. The organisms responsible for post neonatal infections are Staphylococcus areus, Klebsialle Proteus, E.coli, salmonella pseudomonas, Candida Albicans  

15. ON THE BASIS OF LOCATION:- The infection can be superficial or systemic 1.Superficial infections: the infection occurs on the outer side of body. The common sites of superficial infections are eyes, skin, umbilicus and oral cavity. 2.Systemic infections: It includes septicaemia, meningitis, pneumonia, necrotising enterocolitis, tetanus neonatorum , systemic candidiasis, DIC(Disseminated intravenous coagulopathy), pyelonephritis etc

16. BASED ON THE CAUSATIVE ORGANISMS Bacterial infections Viral infections Protozoa infections Fungal infections

17. NEONATAL CONJUNCTIVITIS (OPTHALMIA NEONATORUM) INTRODUCTION Inflammation of conjunctiva during first 3 weeks of life is termed as ophthalmic Neonatorum. Sticky eyes without purulent discharge are common during first 2-3 days after birth. Unilateral conjunctivitis after 5 days of life is often due to Chlamydia trachomatis. Purulent conjunctivitis with profuse discharge is usually due to gonococcus which affects one or both eyes within 48 hours of age. Other microorganisms causing neonatal conjunctivitis are streptococcus, staphylococcus, pneumococcal, E.coli, herpes simplex virus etc. Chemical conjunctivitis may occur due to irritation of silver nitrate, soap and local antibiotic drops.

18. DEFINITION Ophthalmic neonatorum was the term used to describe a hyper acute purulent conjunctivitis, usually caused by gonococcus, in the first 10 days of life. –WHO. Ophthalmic neonatrum was the term used that any hyper acute purulent conjunctivitis occurring during the first 10 days of life, usually contracted during birth from infected vaginal discharge of the mother. -Medical Dictionary Neonatal conjunctivitis is swelling (inflammation) or infection of the tissue lining the eyelids in a newborn. Pub Med

19. MODE OF INFECTIONS It includes infected hands of care givers, infected birth canal and cross-infection from other infected infants. Infection can occur directly from other sites of infections like skin and umbilicus.

20. CLINICAL FEATURES Varies with mode of infection and causative organism. The neonate may present with sticky eyes with or without discharge ranging from watery or purulent or muco purulent in one or both eyes. The eyelids may be markedly swollen and stuck together with redness of eyes. Closed eyelids may present due to spasm of orbicularis oculi muscle.

21. PATHOPHYSIOLOGY

22. DIAGNOSTIC STUDIES Culture of the drainage from the eye to look for bacteria or viruses . Slit-lamp examination to look for damage to the surface of the eyeball

23. MANAGEMENT is done with specific antibiotic therapy, after identification of causative organism. The baby should be isolated to prevent cross infection. Sulfacetamide or gentamycin or cholramphenicol drops or erythromycin ointment can be used. For Gonococcal infection penicillin therapy should be initiated promptly. If organism are resistant to Pencillin then cefotaxime or ceftrioxone (50mg/kg IM or IV) are used. Cleaning of the infected eye with sterile cotton swabs soaked in saline should be done after hand washing. Instillation of eye drops be done with proper aseptic techniques.

24. NURSING MANAGEMENT All infants should receive ocular prophylaxis at birth to prevent Gonococcal Opthalmia. Neonates presenting with signs of conjunctivitis should have a conjunctival swab sent for Gram stain and culture. If Gram-negative diplococci are present on the Gram stain results, the infants and their parents should be treated immediately for presumed gonorrhoea. Infants with chlamydial infection should be treated with oral antibiotics. Most of all other forms of bacterial conjunctivitis can be treated with topical antibiotics, with the exception of Pseudomonas  infection.

25. Infants should be followed during their treatment and upon completion of therapy to ensure resolution of symptoms. For cases in which sexually transmitted bacteria are implicated, the mothers and their sexual partners should be treated. Five clean practices should be followed during delivery; clean hands, clean tie, clean blade and clean cord stump . Sixth clean practice include clean clothing for mother & baby Hand washing before and after handling the babies. Maintenance of cleanliness of the environment i:e delivery room , neonatal care unit , postnatal area and separate area for mother and baby at home

26. CONGENITAL SYPHILIS Syphilis is caused by Treponema pallidum . Congenital syphilis occurs when the spirochete Treponema palladium is transmitted from a pregnant woman to her fetus. Infection can result in stillbirth, prematurity, or a wide spectrum of clinical manifestations; only severe cases are clinically apparent at birth. WHO

27. RISK FACTORS Baby has an increased risk of developing congenital syphilis in following conditions: Lack of inadequate prenatal care of mother. Maternal substance abuse. Failure to repeat a serological test for syphilis in the third trimester. Treatment failure. Inadequate access to Sexually Transmitted Diseases (STD) clinics and STD outreach activities.

28. MODES OF TRANSMISSION Sexual contact. Trans-placental passage from infected mother. Contact with lesion at the time of delivery. The risk of developing syphilis after exposure is about 40%.

29. TYPES 1.Acquired syphilis is transmitted almost exclusively by sexual contact, including oral sexual exposure. Less common modes of transmission include transfusion of contaminated blood or direct contact with infected tissues

30. 2. Congenital syphilis results from transplacental transmission of spirochetes. Women with primary and secondary syphilis and spirochetemia are more likely to transmit infection to the fetus than are women with latent infection. Transmission can occur at any stage of pregnancy. The incidence of congenital infection in offspring of untreated or poorly treated infected women remains highest during the first 4 yr after acquisition of primary infection, secondary infection and early latent disease. Risk factors most commonly associated with congenital syphilis are lack of prenatal care and cocaine drug abuse, unprotected sexual contact, trading of sex for drugs, and poor treatment of syphilis during pregnancy.

31. CLASSIFICATION 1. EARLY : It occurs in children between 0 and 2 years old. 2. LATE : Late congenital syphilis is a subset of cases of congenital syphilis

32. PATHOPHYSIOLOGY

33. CLINICAL MANIFESTATIONS AND LABORATORY FINDINGS Many persons infected with syphilis are asymptomatic for years or do not recognize the early signs of disease. Hutchinson's trait Scarring skin around the mouth & nasal discharge Secondary lesions on feet Lesions on face Hutchinson's teeth (Abnormal notched and peg-shaped, blunted upper incisor teeth) Saddle nose (collapse of the bony part of nose) Clutton's joints (swelling of joints) Sabre shins ( malformation of tibia) Osteochondritis of distal radius and ulna Papulosquamous Plaques Osteochondritis of femur and tibia metaphysis

34. MANAGEMENT Infected baby with positive serological reactions requires: Isolation from the mother Intramuscular administration of aqueous procaine Pencillin G 50,000units per kg body weight each day for 10 days OR Aqueous crystalline Penicillin G 100,000-150,000U/kg/ day (given q8-q12hrs) IV for 10 days If >1 day of therapy missed, entire course should be restarted Positive serological reaction without clinical evidences of disease- the baby is treated with a single intramuscular dose of penicillin G 50000 Units Per Kg Body Weight An Apparently Healthy Child Of A Known Syphilitic Mother-Serological Reaction Should Be Tested Weekly For The First Month And Then Monthly For 6 Months.

35. Follow up Baby must have careful follow-up examination at 1, 2, 4, 6, and 12 months of age. Serologic non- treponemal tests: 3, 6, 12 months and end of treatment (or until non-reactive) Non- treponemal Ab titers decline by 3 months of age, and should be Non-reactive by 6 months, if infant was not infected.(transplacentally acquires antibodies.) If persistent, stable titers, consider retreatment. Congenital neurosyphilis - CSF exam at 6 month intervals until normal

36. HIV AND AIDS In 2009, the World Health Organization (WHO) estimated that there are 33.4 million people worldwide living with HIV/AIDS, with 2.7 million new HIV infections per year and 2.0 million annual deaths due to AIDS. At the end of 2010, there were 3.4 million children living with HIV around the world. An estimated 3,90,000 children became newly infected with HIV in 2010. HIV is primary cause of AIDS. There are different strains of HIV. HIV -2 is prevalent in Africa, where as HIV-1 is more common form in the United States. The majority of children with HIV infection are younger than 7 years of age.

37. DEFINITION An infectious disease of the immune system caused by a human immuno deficiency virus (HIV). AIDS is characterized by a decrease in the number of helper T cells, which causes a severe immune deficiency that leaves the body susceptible to a variety of potentially fatal infections. OR A disease of the immune system characterized by increased susceptibility to opportunistic infections, as pneumocystis carinii pneumonia and candidiasis, to certain cancers, as Kaposi's sarcoma, and to neurological disorders caused by a retrovirus.

38. ROUTES OF TRANSMISSION

39. MATERNAL INFANT TRANSMISSION Intrauterine: 25-40% Intrapartum : 60-75%. Added risk of breast -feeding: 12-14%.

40. RISK FACTORS OF PEDIATRIC AIDS Mothers who addicted with intravenous drugs. Mothers who indulge in prostitution. Mothers who are heterosexual with bisexual husbands. A history of blood transfusion with blood or its products including factor-8 concentrates with in preceding 5 years. A history of residence in certain geographical areas that are inhabited considerably with aids patients.

41. ETIOLOGY HIV is primary cause of AIDS. There are different strains of HIV. HIV -2 is prevalent in Africa, where as HIV-1 is more common form in the United States. Horizontal transmission of HIV occurs through intimate sexual contact or paternal exposure to blood or body fluids containing visible blood Vertical –perinatal transmission occurs when an HIV infected pregnant women passes the infection to her infant. There is no evidence that the casual contact between the infected and uninfected individual can spread the virus. The majority of children with HIV infection are younger than 7 years of age. Children with HIV fall into two subpopulations: infants born to HIV-infected women and adolescents infected as a result of high-risk behaviours. The transmission of HIV can occur in utero, intrapartum , or after delivery through breastfeeding.

42. Nevirapine administered to the mother at labor and to the infant within 48 to 72 hours of life is the most popular regimen in the developing world because of its ease of administration and low cost The World Health Organization has recommended that pregnant women be treated with an antiretroviral regimen appropriate for their own health if possible Since breastfeeding is essential for infant survival in developing countries, HIV mothers on antiretroviral treatment who exclusively breastfed for a duration of their own choosing had lower HIV-1 breast milk concentrations than mothers who abruptly weaned the infant at approximately 4 months of age

43. Transfusion of infected blood or blood products has accounted for 3% to 6% of all pediatric AIDS cases to date Sexual contact is the leading source of exposure to HIV in the United States. In the young pediatric population this is an infrequent route of transmission; a small number of children have been infected through sexual abuse. In contrast, sexual activity is a major cause of HIV infection in adolescents. Given that the average time from HIV infection to the development of AIDS in adults is 10 years.

44. Clinical manifestations Clinical manifestations found more commonly in children than adults with HIV infection include Recurrent bacterial infections, chronic parotid swelling, lymphocytic interstitial pneumonitis (LIP) and early onset of progressive neurologic deterioration. Overall progression of disease is more rapid in children . Immune system is more immature than adults. Recurrent invasive bacterial infections are more common in children . Disseminated CMV, Candida, Herpes Simplex and Varicella Zoster are more common . CNS infections are common . Peripheral neuropathy, Myopathy is rare in children.

45. Categories The HIV classification system is used to categorize the stage of pediatric disease by using 2 parameters: clinical status and degree of immunologic impairment Among the clinical categories, category A (mild symptoms) includes children with at least 2 mild symptoms such as lymphadenopathy, parotitis, Hepatomegaly, Spleenomegaly, dermatitis, and recurrent or persistent sinusitis or otitis media Category B (moderate symptoms) includes children with LIP, oropharyngeal thrush persisting for >2 mo, recurrent or chronic diarrhea, persistent fever for >1 mo, hepatitis, recurrent (HSV) stomatitis, HSV esophagitis, HSV pneumonitis, disseminated varicella (i.e., with visceral involvement), cardiomegaly, or nephropathy Category C (severe symptoms) includes children with opportunistic infections (e.g. oesophageal or lower respiratory tract candidiasis, cryptosporidiosis (>1 mo), disseminated mycobacterial or cytomegalovirus infection, Pneumocystis pneumonia, or cerebral toxoplasmosis [onset >1 mo of age]), recurrent bacterial infections (sepsis, meningitis, pneumonia), encephalopathy, malignancies, and severe weight loss.

46. WHO CLINICAL STAGING SYSTEM CLINICAL STAGE I Asymptomatic General Lymphadenopathy CLINICAL STAGE II Diarrhea >30 days Sever persistent or recurrent diarrhea outside neonatal period. Weight loss failure to thrive Persistent fever >30 days Recurrent sever bacterial infection other than Septicemia or Meningitis. (e.g. Osteomylitis , Abscess, Bacterial Pneumonia-non tubercular)

47. CLINICAL STAGE III AIDS defining opportunistic infections. Sever failure to thrive. Progressive Encephalopathy. Malignancy. Recurrent Septicemia or Meningitis.

48. DIAGNOSTIC EVALUATION For children 18 months of age and older, the HIV enzyme linked immunosorbent assay (ELISA) and Western blot immunoassay are performed to determine HIV infection. In infants born to HIV-infected mothers, other diagnostic tests are used, most commonly the HIV polymerase chain reaction for detection of proviral DNA. With this technique, almost all infected infants can be diagnosed between 1 to 6 months of age

49. MANAGMENT The goals of therapy for HIV infection include slowing the growth of the virus, preventing and treating opportunistic infections, and providing nutritional support and symptomatic treatment. Antiretroviral drugs work at various stages of the HIV life cycle to prevent reproduction of functional new virus particles. Antiretroviral therapy regimens are continually evolving.

50. Although antiretroviral drugs are not a cure, they can delay progression of the disease. Classes of antiretroviral agents include nucleoside reverse transcriptase inhibitors (e.g., zidovudine , didanosine , stavudine , lamivudine , abacavir ); nonnucleoside reverse transcriptase inhibitors (e.g., nevirapine , delavirdine , efavirenz ); and protease inhibitors (e.g., indinavir , saquinavir , ritonavir , nelfinavir , amprenavir , lopinavir , ritonavir ). Combinations of antiretroviral drugs are used to stall the emergence of drug resistance, which has been observed historically in some children who received a single drug

51. IMMUNIZATION HIV-exposed children should be immunized according to the routine national immunization schedule with the following notes: BCG should not be given in symptomatic HIV-infected children. HiB vaccine should be given to all who are confirmed HIV-infected Additional vaccines such as Pneumcoccal , Varicella, Hepatitis A, Influenza Virus etc. may be given as necessary. Vitamin A supplementation should be as per the UIP schedule.

52. NURSING CARE MANAGEMENT Education concerning the transmission and control of infectious diseases, including HIV infection, is essential for children with HIV infection and anyone involved in their care. The basic tenets of standard precautions should be presented in an age appropriate manner, with careful consideration of the educational level of the individual Safety issues, including appropriate storage of special medications and equipment (e.g., needles and syringes) are emphasized.

53. Unfortunately, relatives, friends, and others in the general public may be fearful of contracting HIV infection, and criticism and ostracism of the child and family may occur. In an effort to protect the child and deal with the community’s fear, the family may limit the child’s activities outside the home. Although certain precautions are justified in limiting exposure to sources of infections, they must be tempered with concern for the child’s normal developmental needs. Both the family and the community need ongoing education about HIV to dispel many of the myths that have been perpetuated by uninformed persons.

54. Prevention is a key component of HIV education. Educating adolescents about HIV is essential in preventing HIV infection in this age-group. Education should include information on the routes of transmission, the hazards of IV and other recreational drug use, and the value of sexual abstinence and safe sex practices