Neonatal.sepsis.infection.in.neonates.pptx

Neonatal sepsis

1. Neonatal Seps is Dr Sarfaraz Assistant professor pediatrics

2. Neonatal sepsis Neonatal sepsis is a clinical syndrome of systemic illness accompanied by bacteremia occurring in the first month of life. Also defined as generalized systemic features of infection,associated with pure growth of pathogens from one or more tissue sites or bodyfluids,in a newborn upto 28 days of life. When pathogenic bacteria gain access into the blood stream, – they may cause overwhelming infection without much localization (septicemia),or may get predominantly localized to some particular organ and cause pneumonia,meningitis, UTI, osteomyelitis, septic arthritis, omphalitis,conjunctivitis and necrotizing enterocolitis.

3. Classification of neonatal sepsis Neonatal sepsis can be classified into two sub-types depending upon time of onset of symptoms and signs: Before 72 hours of life (early onset sepsis). After 72 hours of life(late onset sepsis).

4. Early onset neonatal sepsis (EONS) Mainly due to pathogens acquired before and during delivery,i.e, by organisms prevalent in genital tract or in the labor room or O.T. Etiology: Gram E.coli and GBS.less common: Listeria monocytogenes, S aureus, enterococci, other gram-negative bacteria (Klebsiella, Citrobacter, Serratia, and Enterobacter), anaerobes (especially Bacteroides fraglis), Haemophilus influenzae, and Streptococcus pneumoniae.

5. Late Onset Neon atal Sepsis ( LONS) Late-onset sepsis (LOS): It presents after 72 hours of life. LOS can be either healthcare-associated (HAI) or community-acquired infection. Usually assepticemia, pneumonia, or meningitis. Risk factors : prematurity, low birth weight, admission to the intensive care unit, mechanical ventilation, presence of invasive lines, administration of parenteral fluids, poor hygiene, poor cord care, bottle feeding, and prelacteal feed s. Coagulase-negative staphylococci (CONS), especially Staphylococcus epidermidis (53% of cases). Gram-negative rods: Pseudomonas, Klebsiella, Serratia, E. coli, Proteus. Others: S. aureus (MSSA/MRSA), GBS, fungal pathogens.

6. Risk Factors for EOS Prematurity and Low Birthweight: Most significant factor for EOS. Rupture of Membranes ≥18 Hours. Maternal peripartum infection.Includes chorioamnionitis (maternal fever), UTI (esp. GBS bacteriuria), rectovaginal GBS colonization, and perineal E. coli colonization. Previous delivery of a neonate with group B streptococcal disease. Males affected 4x more than females. Black African descent Fetal and intrapartum distress.Includes intrapartum fetal tachycardia, meconium-stained amniotic fluid, traumatic delivery, or severe depression at birth requiring intubation/resuscitation. Multiple gestation. Metabolic factors.Hypoxia, acidosis, inherited disorders (e.g., galactosemia predisposing to E. coli sepsis), and immune defects (e.g., asplenia) increase risk and severity.

7. Risk Factors for LONS Prematurity & Low Birthweight Invasive Procedures/Devices Prolonged ventilation, extended hospital stay, invasive devices,Bottle feeding. Black African descent: Independent risk for GBS sepsis (EOS & LOS). NICU staff/family as vectors due to poor hand hygiene. Longer NICU stay correlates with higher infection risk. Breakage of the natural barriers (skin and mucosa) H2-receptor blocker or proton pump inhibitor use

8. Clinical features of EOS Initial diagnosis of sepsis is clinical, requiring treatment before culture results. Signs and symptoms are nonspecific; differential diagnosis is broad( RDS,MAS,TTNB,Aspiration, ICH,drug withdrawal, asphyxia, IEMs). Some signs are subtle or insidious, necessitating a high index of suspicion to identify and evaluate infected neonates.

9. C/Fs Common clinical signs and symptoms include: Temperature irregularity: Hypothermia ( preterms>terms),hyperthermia ( more in terms and in viral sepsis Change in behavior: Lethargy, irritability, seizures, or change in tone. Skin changes: Poor perfusion, cyanosis, mottling, pallor, petechiae, rashes, sclerema, and jaundice. Cardiopulmonary issues: RD,tachycardia,bradycardia, hypotension, apnea. Metabolic abnormalities: hyperkalemia, hyponatremia, hyperglyce-mia, or metabolic acidosis.

10. Additional clinical features in LONS apnea, bradycardia and desaturation episodes Abdominal distension, visible bowel loops. Focal Infections: Examples: Cellulitis, impetigo, soft tissue abscesses, omphalitis, conjunctivitis, otitis media, meningitis, osteomyelitis. Patients with feeding intolerance and bloody stool may have necrotizing enterocolitis (NEC), gastrointestinal perforation, or obstruction.

11. Meningitis Common signs:Presentation as for neonatal sepsis, others may include bulging anterior fontanelle, focal or generalized seizure, nuchal rigidity . Blood culture and urine culture be obtained CSF WBC >20-30 cells/µL suggests meningeal inflammation;CSF sugar <50% of simultaneously obtained blood sugar  CSF protein >150mg/dl, Presence of microorganisms on culture ofCSF sample . Rx: antibiotics for 14 to 21 days

12. Ophthalmia neonatorum Conjunctivitis in newborns within the first month of life. S. aureus, H. influenzae, S. pneumoniae, enteric Gram-negative bacilli, Group B Streptococcus, N. gonorrhoeae, Chlamydia trachomatis,Herpes simplex virus,Chemical conjunctivitis. Purulent ocular discharge, eyelid erythema/edema, conjunctival injection. Complications: corneal ulceration/scarring,pseudomembrane, risk of pneumonia. Dx: Cultures and gram stain Rx: topical or systemic antibiotics

13. Omphalitis Risk 6x higher for home births vs. hospital births. Low birth weight, prolonged rupture of membranes, umbilical catheterization, improper cord care,Unhygienic substance application. Polymicrobial or anaerobic infections . Purulent, possibly foul-smelling drainage from umbilical stump,Erythema, induration, tenderness; systemic signs. Complications: Necrotizing fasciitis, peritonitis, intra-abdominal abscess, thrombophlebitis, umbilical hernia with bowel ischemia. Dx : Gram stain and culture,Blood and CSF cultures. Rx : systemic antibiotics for 10 days

14. Osteomyelitis and septic arthritis Metaphyseal blood vessels supply cartilaginous epiphyses, leading to epiphyseal damage and joint infections. Commonly by : S. aureus, E. coli, Group B Streptococcus (GBS). Irritability, poor feeding, fever, pseudoparalysis, joint/limb swelling, pain with passive motion. Comolications: Growth plate damage, avascular necrosis, limb length discrepancies, angular joint deformities. Rx: systemic antibiotics for 4-6weeks,candidal- 6 months.

15. Neonatal Pneumonia Early-onset (within 3 days): Vertical transmission (infected amniotic fluid, transplacental). Late-onset (after 1 week): Environmental pathogens; highest risk in ventilated preterm infants. Respiratory distress (tachypnea, retractions, nasal flaring, grunting), apnea. Chest radiographs show bilateral alveolar density, air bronchograms, patchy infiltrates; pleural effusions Blood/CSF cultures; tracheal aspirates (reliable only immediately post-intubation). Rx: respiratory support and antibiotics for 10 days.

16. Urinary tract infections Males > females in neonatal period; females > males by 1 year. Uncircumcised males at higher risk due to bacterial colonization. Hematogenous spread (common, ~1/3 with bacteremia) or ascending infection with urinary tract abnormalities (20%-50% of cases): Vesicoureteral reflux (VUR), ectopic ureter, posterior urethral valves, renal dysplasia. 80% by E.coli Complications: Bacteremia (1/3 of cases), meningitis (1%-2%), renal scarring, hypertension, chronic kidney disease. Dx: urine culture, Renal ultrasound, Voiding cystourethrogram,Renal scintigraphy. Rx: Systemic antibiotics for 7-14 days .

17. Diagnosis Is based on clinical features and laboratory findings including: Cultures: Blood culture It is the gold standard for the diagnosis of sepsis and must be performed in all neonates with suspected sepsis. A positive blood culture with a known sensitivity pattern of the isolated organism is the best guide to antimicrobial therapy. One ml of blood is adequate for a blood culture bottle containing 5-10 ml of culture broth. Tracheal aspirate, cerebrospinal fluid (CSF) for cultures.Body surface cultures not recommended. In critically ill infants, treat for “presumed” sepsis despite negative cultures.

18. Lumbar Puncture (LP): controversial: Clinically ill infants,Infants with CNS symptoms (e.g., apnea, seizures),Positive blood cultures,Prolonged antibiotics (>48 hours) for presumptive sepsis. Molecular testing: Polymerase chain reaction (PCR),DNA microarray-based methods. Complete Blood Count (CBC) with Differential. CBC: Reference values for WBC and absolute neutrophil counts vary by postnatal age (peak at 12–14 hours). look for Neutropenia,Immature Forms,I/T Ratio (>0.2),Decreased platelet count.

19. Sepsis screen Confirms diagnosis in neonates suspected of sepsis. Antibiotics may start without screen results if strong clinical suspicion and neonate is critically ill. Components of Sepsis Screen Total Leukocyte Count (TLC) Absolute Neutrophil Count (ANC): Reference ranges- Manroe’s Charts,Mouzinho’s Charts. Immature to Total (I/T) Neutrophil Ratio: >0.2 is significant Microerythrocyte Sedimentation Rate (mESR): >15mm in isthmus hour. C-Reactive Protein (CRP): >1m/L. Positive Screen: ≥2 abnormal parameters Procalcitonin is indicator of late onset sepsis, more reliable than CRP.

20. Other tests X-ray: For RD or abdominal distension In EOS, lumbar puncture is performed in the presence of a positive blood culture in an asymptomatic neonate with a maternal risk factor or if the neonate is symptomatic with a clinical picture consistent with sepsis. Urine cultures have a low yield and are not indicated routinely and in EOS . However, neonates at risk for fungal or suspected urinary tract infection or with risk factors should have a urine examination to exclude UTI. Urine cultures are obtained by suprapubic puncture, bladder catheterization, or clean catch samples from midstream urine.

21. CSF