Neonatal Infections

Newborn infections and their treatment and prevention

1. NEONATAL INFECTIONS Presented by: Jaspreet Kaur B. Sc (N) 4 th Year

2. DEFINITION OF NEONATAL INFECTIONS : Invasion and uncontrollable growth of pathogenic microorganisms in the body of neonate is known as neonatal infections. MODE OF INFECTION : Antenatal Intranatal Postnatal

3. MODE OF INFECTION : ANTENATAL : Transplacental : Maternal infections may occur due to various microorganisms 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 H: Herpes Simplex Virus

4. MODE OF INFECTION : INTRANATAL : Aspiration of infected liquor or meconium following early rupture of membranes which may lead to neonatal aspiration pneumonia . Infected birth passage may infect the eyes and mouth of neonate leading to Ophthalmia neonatorum and oral thrush . Improper aseptic technique during care of umbilical cord may cause umbilical sepsis .

5. MODE OF INFECTION : POSTNATAL : Transmission of infection from human contact or caregivers 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 Infected environment around the neonates at hospital or home

6. OPHTHALMIC NEONATORUM (CONJUNCTIVITIS)

7. 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. Causes : Unilateral conjunctivitis after five days of life is often due to Chlamydia trachomatis Other bacterial causes: Gonococcus, staphylococcus, pseudomonas Viral: herpes simplex Chemical: Silver nitrate

8. Mode of infection : It includes infected hands of the caregivers, infected birth canal and cross infection from other infected infants. During neonatal period, there may be direct contamination from other sites of infection like skin and umbilicus. Clinical Features : The neonate may present with sticky eyes with or without discharge ranging from watery or purulent or mucopurulent in one or both eyes. The eyelids may be markedly swollen and stuck together with redness of the eyes. Cornea may be involved in severe cases.

9. COMPLICATIONS : Keratitis Conjunctival scarring Superior corneal pannus Permanent visual impairment 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 eyeball. TREATMENT : Gonococcal Conjunctivitis : Topical administration of broad spectrum antibiotics (gentamicin eye drops every hour) + A single dose of ceftriaxone(75-100m/kg/day IV or IM QID FOR 7 days)

10. TREATMENT : Chlamydial Conjunctivitis : Topical erythromycin eyedrops (5x/day) + Oral erythromycin(50 mg/kg/d divided QID) Herpetic Conjunctivitis : - Acyclovir eye ointment - Systemic acyclovir 30 mg/kg/day IV TID, for 14 days up 21 days (in severe cases) PREVENTION : Infection can be prevented by cleaning the eyes immediately after birth and applying either 1% silver nitrate solution, 1% tetracycline or 0.5% erythromycin ointment to the eyes with in one hour of the delivery.

11. OMPHALITIS (Umbilical Sepsis)

12. DEFINITION : Omphalitis is the medical term used for inflammation of the umbilical cord stump in the neonatal newborn period, commonly attributed to a bacterial infection. CAUSES : The culprits usually are Staphylococcus aureus, Streptococcus and Escherichia coli. The infection is typically caused by a combination of these organisms and is a mixed Gram-positive and Gram- negative infection. Anaerobic bacteria can also be involved.

13. CLINICAL FEATURES : Patient present with redness and swelling (Cellulitis) around the umbilicus Purulent or mal odorous discharge from the umbilicus Baby is highly irritable Delay in the falling off the cord The cellulitis is rapidly progressive and may lead to necrotizing fasciitis SPREAD OF INFECTION : Thrombophlebitis of the umbilical vein with extension of the infection to the liver producing hepatitis or pyemic liver abscess Peritonitis

14. DIAGNOSTIC STUDIES : Obtain specimen from umbilical infection for Gram stain & culture for aerobic and anaerobic organisms. Blood culture for aerobic and anaerobic organisms CBC Treatment : Antimicrobial Therapy : A combination of parenterally administered anti- staphylococcal penicillin and an Aminoglycoside is usually recommended (coverage for gram-positive and gram- negative organisms). CLOXACILLIN + GENTAMYCIN For anaerobic coverage, CLOXACILLIN + GENTAMYCIN + METRONIDAZOLE As with anti-microbial therapy, local antibiotic sensitivity pattern is considered.

15. TETANUS NEONATORUM

16. DEFINITION : Neonatal tetanus is the generalized tetanus infection of the newborn. It usually gets transmitted from an unvaccinated mother and enters the body through the infection of unhealed umbilical stump. This typically happens when the umbilical cord is cut using unsterile instruments. CAUSATIVE ORGANISM: Clostridium tetani CLINICAL FEATURES : The features are evident with 5-15 days after birth. Initial symptom is inability to suck and inability to open mouth known as trismus, irritability and excessive cry.

17. Then develop risus sardonicus With in12-24 hours after the first, generalized tonic convulsions occur producing flexion and adduction of the arms, clenching of fists and extension of the lower extremities. Initially spasms are mild but later become severe with spasms of glottis and respiratory muscles. Opisthotonos (the muscle spasms will cause child’s back to be severely arched and child’s heels and head will be bent back to an extreme degree)

18. TREATMENT : Isolate the baby in dark and silent room Washing and debridement of the infected site and administration of antibiotics such as Benzyl penicillin or Metronidazole. Anti-toxin, Anti-tetanus serum (50,000- 1,00,000 U) Human tetanus immunoglobin (3,000-6,000 U) Sedation: Diazepam 0.1-0.2 mg/kg Phenobarbitone 15mg/kg per day in divided doses Feeding by: NG Tube Daily milk requirement- 100-120ml/kg/day

19. NECROTISING ENTROCOLITIS

20. DEFINITION : Necrotizing enterocolitis is an intestinal (bowel) disease that primarily affects the premature infants. “Necrotizing” refers to cell damage and death, “entero” to the intestine and “colitis” to inflammation that occurs in the lower intestine (colon). RISK FACTORS : Premature infants Perinatal asphyxia Hypotension Polycythaemia Septicaemia due to E.coli., Klebsiella, Pseudomonas Umbilical cord catheter related thromboembolism Exchange Transfusion

21. CLINICAL FEATURES : Systemic signs: Respiratory distress Lethargy Feeding intolerance Hypertension Acidosis Oliguria Bleeding diathesis Abdominal signs Abdominal distension Tenderness Bloody stools Vomiting bile(which appears green)

22. DIAGNOSTIC STUDIES : 1.Abdominal X-ray: Pneumoperitoneum (presence of air or gas in the abdominal cavity) indicates perforation 2. Ultrasonography: may detect microbubbles of gas within the portal vein 3. Stool analysis

23. TREATMENT : Stopping all regular feedings. The baby receives nutrients through intravenous (IV) catheter. Placement of a nasogastric tube. The tube suction air and fluids from the baby’s stomach and intestine, relieving swelling and discomfort. Starting antibiotic therapy. If abdominal swelling interferes with breathing, providing oxygen or mechanically assisting breathing. Taking frequent blood test to detect signs of infection and imbalances in the body’s chemistry. In severe cases, platelet and red blood transfusion may be necessary. Bowel resection in case of perforation.

24. ORAL THRUSH

25. DEFINITION : Oral thrush is an infection of yeast fungus, Candida albicans that appears as whitish, velvety lesions in the mouth and on the tongue. It is common in infants. CAUSES : Oral thrush may occur in babies because their immune systems have not yet matured. They are less able to resist infection. An oral thrush can happen after treatment with antibiotics, because antibiotics reduce the levels of healthy bacteria in the mouth. This allows fungus to proliferate. If a mother had to deal with vaginal yeast infection, then a baby could have picked up Candida in the birth canal. If a mother breastfeed and her nipples are red and sore, she might have a yeast infection on her nipples, which a mother and a baby can pass back and forth.

26. CLINICAL FEATURES : Usually appear in the late 1 st week or during the second week Soft whitish adherent patches on oral mucous Painless Removed with little difficulty TREATMENT : Topical: Nystatin (100,000 U/ml), 1 ml is applied to each side of the mouth QDS for 7-10 days Systemic : Fluconazole (50mg/day) for 7-10 days PREVENTION : Maternal fungal infection is to be adequately treated before delivery. Utensils including feeding bottles and teats are to be properly cleansed before & after each feed.

27. SKIN INFECTIONS

28. DEFINITION : A skin infection is a condition where bacteria or other germs enter the skin through a wound and spread, causing pain, swelling and discoloration. Newborn’s skin infections may manifest as skin rashes, pustulosis or cellulitis. PUSTULOSIS Historically referred wrongly as neonatal acne because of their clinical similarity Presents in the first 3 weeks of life Postulated to develop in association with Malassezia (fungal infection) Site – cheeks, chin, eyelids, neck and upper chest

29. TREATMENT: Self-limiting nature, heals in 1-3 months without scarring Persist/widespread- 2% ketoconazole cream for 15 days 2. CELLULITIS Deep bacterial infection of the skin Infection usually involves the face, arms and legs Caused by the bacterial infection of a wound area of skin that is no longer intact. The most common causative organisms are: Group A B – Hemolytic streptococcus, Streptococcus pneumoniae and Staphylococcus aureus In severe infections or in a premature infant, complete blood count (CBC) and blood culture are to be obtained. TREATMENT : Systemic antibiotic (Oxacillin or Nafcillin and Gentamicin) IV is given.

30. PREVENTATIVE INTERVENTIONS FOR INFECTIONS IN NEWBORN : Improved nutrition during pregnancy. Identification and treatment of infections in mother 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. Handwashing before and after handling of the babies. Maintenance of cleanliness of the environment i.e. delivery room, neonatal care unit and postnatal area. Improved newborn care practices(breastfeeding, cord care, thermal care) Extra care and attention to preterm/LBW

31. NURSING DIAGNOSES : Infection related to presence of microorganisms in the body Hyperthermia or hypothermia related to infectious process Impaired skin integrity related to presence of lesions Delayed growth and development related to inadequate feeding and presence of infection Impaired parenting related to separation secondary to admission in the NICU.

32. BIBLIOGRAPHY : Dutta D.C. . Textbook of Obstetrics . Seventh edition . New Central Book Agency Publications . Kolkata . Page no. 487-491 www.medicalnewstoday .com www.healthline.com

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