Neonatal sepsis FOR pharmacy student.ppt

PHARMACY

1. TADESSE GETAHUN ,JULY 3 /07
Approach to the newborn and
young infant with Suspected
sepsis (PROM)

2. Out line
Over view of neonatal sepsis
Risks of neonatal sepsis
Management options
Preventive strategies
References

3. Overview of neonatal sepsis
Throughout pregnancy and until the membranes
rupture, the fetus is relatively protected from the
microbial flora of the mother by
-the chorioamniotic membranes
-the placenta, and
-poorly understood antibacterial factors in
amniotic fluid.

4. Overview of neonatal sepsis cont..
However there are many ways:
Procedures disturbing the integrity of the uterine
contents, such as amniocentesis, cervical
cerclage,transcervical chorionic villus sampling,
or percutaneous blood sampling
Certain bacteria, particularly Treponema
palladium & Listeria monocytogenes, can reach
the fetus through the maternal bloodstream
despite placental protective mechanisms, causing
transplacental infection.

5. Overview of neonatal sepsis cont..
Initial colonization of the neonate usually takes place
after rupture of the maternal membranes.
In most cases, the infant is colonized with the
microflora of the birth canal during delivery.
Fetal infection can result from aspiration of
infected amniotic fluid , leading to stillbirth,
premature delivery, or neonatal sepsis.

6. Overview of neonatal sepsis cont..
Infection of the mother at the time of birth,
particularly genital infection, is the principal
pathway of maternal transmission and can play an
important role in the development of infection in the
neonate.
 Finally, bacteria can be introduced after birth from
the environment surrounding the
baby, either in the nursery or at home.

7. Overview of neonatal sepsis cont..
Many pre- and intrapartum obstetric complications
are associated with an increased risk of infection in
newborn infants.
 Among these are premature onset of labor,
prolonged rupture of the fetal membranes, uterine
inertia with high forceps extraction, and maternal
pyrexia

8. Overview of neonatal sepsis cont..
Neonatal Sepsis- continues to be a major cause
of morbidity and mortality for newborn infants.
 The clinical symptoms are very non-specific,&
the consequences of a delayed diagnosis can be
devastating.
This can include death or significant neurologic
impairment secondary to CNS infection,
metabolic derangement, and cardiovascular
instability.

9. Risk Factors
Maternal
− Prolonged rupture of membranes
− Group B Streptococcus colonization
− Sustained fetal tachycardia
− Suspected chorioamnionitis
− Maternal fever
− Preterm labor
− Foul smelling amniotic fluid

10. Risk Factors (cont..)
Neonatal
− Low birth weight
− Prematurity
− Twin gestation

11. An assessment should be made of neonatal risk
factors for sepsis, especially for Group B
streptococcal(GBS) infection.
Risk factors for neonatal infection include:
Intrapartum temperature 100.4ºF (38.5ºC)
Membrane rupture > 18 hours
Delivery at <37 weeks gestation
Chorioamnionitis
Risk Factors (cont..)

12. Risk Factors (cont..)
Prematurity and LBW
The excess risk of EOGBS disease in preterm and
LBW infants has been well-recognized for many
years. Early reports noted that preterm and LBW
infants were over represented among infants with
early-onset disease.

13. Risk Factors (cont..)
Prematurity & low birth wt.
Prolonged or premature rupture of AM.
PROM >18hrs OR= 7.8
only few cases are available.
•Intapartum fever
•Chorioamnionitis OR=6.42 –neonates become septic
inspite of intapartum prophylaxis.

14. Risk Factors (cont..)
Combined intrapartum factors
-intrapartum maternal fever
-PROM and/ or Bwt<2500mg
these constitutes only <20% of cases but has 75% risk
for early onset neonatal sepsis.
Multiple gestation

15. Birth wt (gms)Birth wt (gms)OR(95%CI)OR(95%CI)
500–1000 24.8 (12.2–50.2)
1001–1500 7.45 (2.73–20.3)
1501–2000 8.16 (3.66–18.2)
2001–2500 3.96 (1.91–8.20)
>2500 1.00
ORs for EOGBS Stratified by Birth Weight

16. ORs for EOGBS Stratified by Gestational
Age
Gestational age (mons)Gestational age (mons)OR (95% CI)OR (95% CI)
< 28 32.1 (4.19–265)
28–30 14.8 (3.23–70.3)
31–33 6.89 (1.56–30.8)
34–36 3.25 (.90–11.8)
≥37 1.00

17. Risk Factors Associated With Very High Early-
onset GBS Attack Rates
Clinical Risk Factor Approximate Prevalence
(%)
Twin with early-onset
GBS disease
<<.1
PPROM*in a GBS
colonized mother
<.5
Chorioamnionitis 1–4
GBS bacteriuria during
current pregnancy
2.5
Sibling with early-onset
GBS disease
<1

18. Preventive Strategies
Intrapartum prophylaxis indicted:
-previous infant with GBS disease, OR
-GBS bacteriuria during current pregnancy , OR
-positive GBS screening culture during pregnancy
( unless planned C/S delivery, in the absence of labor
or amniotic membrane rupture, is performed), OR

19. Prevention cont..
-unknown GBS status (culture not done ,incomplete,
or results unknown) AND
Delivery at<37wk gestation ,OR
Amniotic membrane rupture ≥ 18hrs, OR
Intrapartum temperature ≥ 38.0 ºc

20. Prevention cont..
Intrapartum prophylaxis not indicted:
-if patient meets none of the stated
criteria ,intrapartum prophylaxis for GBS is not
indicated this includes:
 previous pregnancy with a positive GBS screening
culture (unless a culture is also positive during the
current pregnancy)

21. Prevention cont..
Planned CS delivery performed in the absence of
labor or membrane rupture (regardless of maternal
GBS culture status)
Negative vaginal & rectal GBS screening culture
during the current pregnancy , regardless of
intrapartum risk factors.

22. Prevention cont..
2002 Guidelines — For prevention of GBS
includes:
All pregnant women should be screened for GBS
colonization with swabs of both the lower vagina and
rectum at 35 to 37 weeks of gestation. The only patients
who are excluded from screening are those with GBS
bacteriuria earlier in the current pregnancy or those who
gave birth to a previous infant with invasive GBS disease.

23. Prevention cont..
Swabs should be obtained from the lower vagina (not
cervix) and rectum (not anal orifice)
Susceptibility testing to erythromycin and
clindamycin, if feasible, should be performed for
GBS isolates.

24. Management of NBS
How to manage & how long to keep under observation of
infants born from mothers who have received IAP is
crucial.
Management options include:
Ill-appearing - If the infant is ill-appearing or sepsis
is otherwise strongly suspected, a full diagnostic
evaluation including a CBC with differential, a blood
culture, and a lumbar puncture should be done

25. Management of NBS cont..
and empiric antibiotic treatment initiated using
ampicillin and gentamicin until laboratory culture
results are known. A chest radiograph should be
obtained if respiratory symptoms are present.

26. Management of NBS cont..
Healthy-appearing- 
 <35 weeks gestation — If the infant is healthy-appearing
and IAP with penicillin, ampicillin, or cefazolin was
administered to the mother at least four hours prior to
delivery, a CBC with differential and blood culture should
be obtained and the infant observed without antibiotic
treatment for at least 48 hours.

27. Management of NBS cont..
Empiric antibiotics are initiated if there is a clinical
suspicion for sepsis based upon the circumstances of the
delivery (e.g., maternal chorioamnionitis), if a change
occurs in clinical status, or if the blood culture yields
GBS.
If C/S delivery observe until work up.

28. Management of NBS cont..
35 weeks gestation — IAP less than four hours prior
to delivery, a CBC with differential and blood culture
should be obtained and the infant observed without
antibiotic treatment for at least 48 hours. Empiric
antibiotics are initiated only if a change in clinical
status occurs or the blood culture yields GBS.

29. Management of NBS cont..
If IAP was begun at least four hours prior to delivery,
the infant does not need further evaluation but
should be observed in the hospital for at least 48
hours.

30. Management of NBS cont..
The 2002 CDC guidelines for management of infants
whose mothers have received IAP:
Infants born to women with suspected or proven
chorioamnionitis should have a full diagnostic evaluation
and initiation of broad-spectrum antibiotics until
laboratory results become available; infants with normal
laboratory results and a benign clinical course may have
antibiotics discontinued after 48 hours.

31. Management of NBS cont..
Infants born at ≥ 38 weeks of gestation whose
mother received IAP at recommended doses 4 hours
prior to delivery can be considered for discharge at
24 hours . Can be observed carefully at home, and a
parent has ready access to a pediatric hospital.

32. Management of NBS cont..
Only infants born to mothers who have received
penicillin, ampicillin, or cefazolin as IAP at the
recommended doses and intervals four or more
hours before delivery should be considered
adequately "treated";
Infants born to women who have received
alternative regimens should be observed for at least
48 hours.

33. Out line
Over view of neonatal sepsis
Risks of neonatal sepsis
Preventive strategies
Management options
References

34. References
1.Behrman,Kliegman,Jenson.Nelson text
book of pediatrics,17
th
edition.
2. Carol J Baker, MD Chemoprophylaxis
for the prevention of neonatal group B
streptococcal disease. UpToDate
version 15.1.

35. References cont..
3. Karen M Puopolo, MD, PhD ,Carol J Baker, MD.
Management of the infant whose mother has
received group B streptococcal chemoprophylaxis.
UpToDate version 15.1.
4. Carol Elaine Adair, Laura Kowalsky,
Harvey Quon,etal. Risk factors for early-
onset group B streptococcal disease in
neonates: a population-based case–control
study. CMAJ2003;169(3):198-203

36. References cont..
5. William E. Benitz, MD; Jeffrey B. Gould, MD; and
Maurice L. Druzin, MD. Risk Factors for Early-
onset Group B Streptococcal Sepsis: Estimation of
Odds Ratios by Critical Literature Review.
American Academy of Pediatrics, Pediatrics
1999;103(6).
6. William E. Benitz, Jeffrey B. Gould and Maurice
L. Druzin. Preventing Early-onset Group B
Streptococcal Sepsis: Strategy
Development Using Decision Analysis.
American Academy of Pediatrics, Pediatrics
1999;103;e76

37. References cont..
7 . Chiesa et al.: Diagnosis of Neonatal Sepsis. Clinical
Chemistry 50, No. 2, 2004